INQUEST INTO THE DEATH OF CHRISTOPHER STUART WILSON … Findings... · Mark Frederick Johns, State...

INQUEST INTO THE DEATH OF

CHRISTOPHER STUART WILSON

“In my view, this case presented opportunities for greater leadership

to be demonstrated and I would have expected greater leadership to

be shown during police involvement in the incidents that have been

examined during this Inquest.” (Deputy Commissioner Burns)

Inquest conducted by Mr Mark Johns, State Coroner, South Australia

CORONERS ACT, 2003

SOUTH AUSTRALIA

FINDING OF INQUEST

An Inquest taken on behalf of our Sovereign Lady the Queen at

Adelaide in the State of South Australia, on the 21st, 23

rd and 28

th days of May 2007, the 28

th

and 29th

days of June 2007, the 13th

, 14th

, 15th

, 16th

, 17th

, 20th

, 21st, 22

nd, 23

rd, 24

th, 27

th, 28

th,

29th

and 30th

days of August 2007, and the 9th

, 19th

, 20th

, 22nd

, 23rd

and 26th

days of November

2007, and the 7th

day of April 2008, by the Coroner’s Court of the said State, constituted of

Mark Frederick Johns, State Coroner, into the death of Christopher Stuart Wilson.

The said Court finds that Christopher Stuart Wilson aged 23 years,

late of 3 Ey Court, Athelstone died at the Royal Adelaide Hospital, North Terrace, Adelaide,

South Australia on the 28th

day of February 2004 as a result of gunshot wounds to head. The

said Court finds that the circumstances of his death were as follows:

1. Cause of death

Christopher Wilson was 23 years of age at the time of his death at 1500 hours on

28 February 2004 at the Royal Adelaide Hospital. On 27 February 2004 Mr Wilson

had sustained a gunshot wound to the back and two shots to the head. He was

conveyed to the Royal Adelaide Hospital where he subsequently died from his

wounds. Post mortem examination confirmed two gunshot entry wounds to the head,

one in the right forehead and the other just below the left ear. Further examination of

the brain showed the right forehead gunshot wound passed right to left, horizontally,

and exited the brain in the left frontal region. The left temporal gunshot wound

passed left to right into the brain and approximately horizontally. Another gunshot

2

wound was located in the left side of the back region, with a projectile path passing

through the tenth thoracic vertebrae. The pathologist also noted that there was an

irregularly shaped abrasion on the lateral aspect of Mr Wilson’s right lower leg. This

abrasion was 17 by 8 millimetres in size and was healing at the time of death.

1. Christopher Wilson’s murderer

1.1. For reasons that appear in paragraph 23 of these findings, the media is forbidden from

publishing the identity of Christopher Wilson’s murderer, because he (the murderer)

was 17 years old at the time of the murder. Although the Coroner’s Court can publish

his name, any further publication by the media of his name would be forbidden by

section 63C of the Young Offenders Act 1993.

1.2. In order to prevent an inadvertent breach of section 63C by media outlets I have

elected to refer to the murderer by the letters “HB”. Had HB murdered Christopher

Wilson just one week later, he would have been 18 years old and this would have

been unnecessary. I have made recommendations about section 63C of the Young

Offenders Act.

1.3. On 4 August 2005 HB pleaded guilty to the offence of murder, two separate offences

of endangering the life of another person and one offence of threatening a person with

a firearm. It was HB who shot Christopher Wilson on 27 February 2004. He used a

Ruger revolver1. HB was sentenced to life imprisonment for the offence of murder

and to a single sentence of imprisonment for nine years for the offences of

endangering life and threatening a person with a firearm. The sentences were directed

to be served concurrently. HB was almost 18 years old on 27 February 20042 and

accordingly he was dealt with under the Young Offenders Act 1993 but was

sentenced as an adult. Justice White directed that the sentences of imprisonment be

served in a prison. He fixed a non-parole period of 16 years and 6 months

commencing on 1 March 2004. Of the offences for which HB was convicted, the

murder, the threatening a person with a firearm and one of the offences of

endangering the life of another person were committed on 27 February 2004 during

an incident that occurred in Duthie Street, Hillcrest in the early hours of that morning.

The other offence of endangering the life of another person occurred late in the

1 Annexure GM37 to Exhibit C10

2 His date of birth was 3 March 1986

3

evening of 25 February 2004 in Flinders Street, Hillcrest. The victim on that occasion

was also Christopher Wilson. The victims of the offences apart from murder that

occurred on 27 February 2004 were Mr Mark Wilson, the brother of Christopher

Wilson, and Mr Justin Williams, a friend of Christopher and Mark Wilson. The

sentencing remarks of Justice White are contained in Exhibit C37c. Those remarks

note that the wound to Christopher Wilson’s back was fired as he was running away

from HB. That wound disabled Christopher Wilson immediately and he fell to the

ground. After that, two shots were fired by HB into Mr Wilson’s head as he lay on

the ground. Justice White described this as indicative of an “execution style killing”

and I respectfully agree.

1.4. Thus, the criminal proceedings which ensued from the death of Christopher Wilson

having been disposed of, section 21(2) of the Coroners Act 2003 did not afford any

obstacle to the commencement of this Inquest on 21 May 2007.

2. Conduct of the Inquest

2.1. Section 20(1) of the Coroners Act 2003 provides:

‘The following persons are entitled to appear personally or by counsel in proceedings

before the Coroner's Court:

(a) the Attorney-General;

(b) any person who, in the opinion of the Court, has a sufficient interest in the subject

or result of the proceedings.’

When the Inquest opened on 21 May 2007 the information then available to the Court

was relatively limited as is evident from the opening submissions of Counsel

Assisting which appear at Transcript, pages 2 to 9. At that time Counsel Assisting me

tendered the following affidavits:

Senior Sergeant Dean Greenlees of Fingerprint Section, South Australia Police

and attached statement of Anneke Lisbeth Sterk dated 1 March 2004

Dr Allan Cala, Chief Forensic Pathologist and attached post mortem report

dated 15 April 2004

Mr Donald Sims, Principal Forensic Scientist of Forensic Science SA and

attached toxicology report dated 21 May 2004

Mr Mark Edmund Wilson sworn 14 May 2007 and attached statements dated

21 May 2004 and 19 November 2004

Detective Inspector Brenton Saunders of Holden Hill Criminal Investigation

Branch, South Australia Police and attached letter from Psychiatrist Nick Ford

4

dated 30 April 2007, and attached letter from Registered Psychologist Michael

Correll dated 4 May 2007

Sergeant Robert Delaat of Adelaide Crime Scene, South Australia Police and

attached statement dated 12 March 2004

The affidavit of Senior Sergeant Greenlees was a formal identification affidavit. The

post mortem report and toxicology reports were likewise essential documents, for the

ascertainment of cause of death but did not provide much indication of the

circumstances leading up to Mr Wilson’s death. The affidavit of Mark Edmund

Wilson was put in at that stage because he would be unable to give evidence by

reason of a psychiatric condition. The affidavit of Detective Inspector Brenton

Saunders related to the inability of another police officer to attend Court by reason of

a medical condition.

2.2. Counsel Assisting’s description of the situation as it appeared from the documents

then available to the Court appears at Transcript, page 3. I set it out hereunder:

‘… late on 25 February 2004, Mr Wilson, his brother Mark, who lived at an address at

John Street at Hillcrest, and three other men in a car, who I'll refer to as Mr Wilson's

group, encountered two other men in a nearby street, and there was apparently some

verbal exchange between some of them.

Your Honour will hear references throughout the course of the inquest to John Street,

which is where Mr Mark Wilson lived, to Duthie Street, to Hawkins Avenue and

Flinders Road, and they are all streets in the same vicinity between Fosters and North

East Roads at Hillcrest.

Mr Wilson's group apparently travelled in a car driven by Mr McAinsh down Duthie

Street, which is a dead end street. They turned and went back onto Hawkins Avenue and

then into Flinders Street, and in statements to police some of them say that they noticed a

particular black BMW car behind them as they exited Duthie Street.

Once they were in Flinders Street, I understand that Mr McAinsh travelled around a

roundabout so that his car was facing in the direction from which it had just come, and it

was at this point that the occupants in that car in their statements describe that they saw a

black BMW car coming towards them. Both of those vehicles stopped and it was at this

time that there was some interchange between the two groups.’

Counsel Assisting then described how one of the occupants of the BMW,

subsequently identified as HB, had a firearm of some description with him. She

described how the firearm was apparently discharged during the encounter and how,

as Mr Wilson’s group drove away from the scene Mr Wilson, who was sitting in the

right rear passenger seat said something to the effect that he thought he might have

been shot, having felt what appeared to be blood on his right calf. As will

5

subsequently appear from a fuller description of this incident, a shot discharged from

HB’s gun ricocheted off the bitumen on Flinders Road and hit Mr Wilson in his right

calf while he was seated in Mr McAinsh’s Magna motor vehicle, in the rear of that

vehicle on the driver’s side with the door open. Shortly afterwards, the Wilson group

attended in the same vehicle at the Holden Hill Police Station to report this incident.

2.3. Counsel Assisting said that the events at the Holden Hill Police Station concerning

what was said by members of the Wilson group to particular police officers and what

action was subsequently taken by police would be a primary focus of the Inquest.

2.4. Counsel Assisting made the point, which I returned to frequently during the course of

Inquest, that the Court had no overall report of the events leading to the fatal shooting

of Christopher Wilson. The documentary information available to the Court at the

commencement of the Inquest related predominantly to the events of 25–27 February

2004. As the Inquest unfolded, it became apparent that there had been another

significant incident which required consideration which came to be referred in the

course of the Inquest as the “Dreelan PIR” or “Dreelan complaint”. That related to a

complaint made to officers at Holden Hill Police Station by a person called Clive

Dreelan in relation to an incident involving HB that had occurred in September 2003,

the complaint having been made in October 2003. The handling of the Dreelan

complaint became the subject of extensive investigation at the Inquest just as did the

handling of the complaint made at Holden Hill Police Station by Christopher Wilson

on the evening of 25 February 2004.

2.5. The lack of any overall report collating all material relevant to the cause and

circumstances of Christopher Wilson’s death meant that new3 material emerged over

the course of the Inquest and required assessment “on the fly”, to an extent not usually

experienced by the Court.

2.6. As a consequence of this, it became necessary to call further witnesses as the

relevance or potential relevance of the accounts of those witnesses became apparent

from evidence adduced by the witnesses that preceded them.

2.7. For that reason the Inquest took an unpredictable course and it was necessary to deal

with applications by Counsel seeking leave to appear on behalf of proposed witnesses

3 I refer to material not previously known to the Court.

6

throughout the Inquest as it unfolded. This was complicated by the fact that it was not

always entirely clear at the time an application was made why the proposed witness

was said to have a sufficient interest in the subject or result of the proceedings. With

the exception of an application on behalf of Mrs Julie Wilson, the mother of

Christopher Wilson, and an application by the Commissioner of Police whose

interests were self evident, there were a number of applications made on behalf of

police officers who were to be called as witnesses during the course of the Inquest. A

person appearing as a witness is not entitled as of right to be represented by Counsel

on the basis that he or she has a sufficient interest in the subject or result of the

proceedings. Something more than an interest as a witness or a proposed witness is

required. Part of the material available to the Court at the commencement of the

Inquest was a letter dated 19 October 2006 from the Police Complaints Authority4 to

Mrs Julie Wilson who had made a complaint against police as a result of her son’s

death. That letter eventually came to be received in evidence as Exhibit C12n. The

letter advised that the Police Complaints Authority had recommended disciplinary

action against four named police officers; Detective Brevet Sergeant Gregory Paul

Ranger, Detective Senior Constable Rohan Wynfield Crawford, Senior Constable

Michael Redding and Sergeant Glenn Mickan. I took the view that any of these

officers who was required to give evidence at the Inquest would, on the face of it, be

entitled to appear by Counsel if an application was made. Beyond those officers,

there was no material before the Court which would offer any obvious basis for an

application made on behalf of a proposed police officer witness other than

submissions provided by his or her Counsel.

2.8. As the Inquest unfolded, it became apparent that a number of other police officers

apart from those referred to in Exhibit C12n had been the subject of investigation by

the Internal Investigation Branch and the Police Complaints Authority in relation to

the circumstances leading to Christopher Wilson’s death. As a consequence of the

lack of any overall report about those circumstances it was not possible for the Court

to predict before the commencement of the Inquest the involvement of those other

police officers.

2.9. In the result, almost every police officer who was called to give evidence at the

Inquest applied for and was granted leave to appear by Counsel. In all there were

4 Exhibit C12n

7

twenty Counsel representing different interests by the completion of the Inquest many

of whom were present in Court for substantial parts of the Inquest.

2.10. I made it plain at the outset that I did not wish to have unnecessary repetition of

questions and that Counsel should confine themselves to questions pertaining to their

client’s interests only and to avoid covering ground which had already been covered

so far as possible. With limited exceptions, this rule was generally adhered to by

Counsel. Nevertheless, there were severe logistical difficulties presented by the

number of Counsel appearing.

3. Police (Complaints and Disciplinary Proceedings) Act 1985

3.1. Prior to the commencement of this Inquest, Counsel Assisting me wrote to the

Commissioner of Police seeking access to an assessment of the Police Complaints

Authority. The Court was aware that such a document existed and that it was 53

pages in length. This was apparent from a letter dated 15 November 2006 from the

Police Complaints Authority to Mrs Julie Wilson a copy of which was admitted as

Exhibit C12q and which had been provided by Mrs Wilson to the Court prior to the

Inquest. Neither the Commissioner of Police nor the Police Complaints Authority

was prepared to provide a copy of the assessment to the Court for use at the Inquest.

The Commissioner of Police was prepared and did offer to provide a copy of the

report to me on the condition that I not divulge its contents. This I declined to do

because it would be of no assistance to me to be aware of material which I could not

use for the purposes of a public Inquest. Having knowledge of matters which I would

not be able to refer to might also create difficulties in the conduct of the Inquest.

3.2. Nevertheless, it became clear at a fairly early stage that there was a significant amount

of material in the hands of both the Commissioner of Police and the Police

Complaints Authority that was relevant to the matters the subject of the Inquest. In

my opinion it was likely that such material would include statements of witnesses,

record of interviews of witnesses, copies of exhibits and various other documents.

3.3. The Inquest was fully conducted without access to any of this material. As the

Inquest unfolded it became apparent that persons not previously understood by me to

have been the subject of disciplinary investigation had in fact been so investigated.

One such person disclosed this fact during the course his evidence. It was not until

very late in the Inquest that Counsel for the Commissioner of Police finally informed

8

the Court (at the Court’s request) of the names of all officers in relation to whom

disciplinary investigations had taken place.

3.4. The Police (Complaints and Disciplinary Proceedings) Act 1985 will hereinafter be

referred to as the “Police Complaints Act”. The Police Complaints Act establishes the

Police Complaints Authority and provides for a Police Disciplinary Tribunal. In

addition to that it provides for the investigation and assessment of complaints against

police. Section 48 of the Act is headed “Secrecy” and provides as follows:

‘(1) In this section—

prescribed officer means—

(a) a person acting under the direction or authority of the Authority; or

(b) a member of the internal investigation branch or any other member of the

police force,

but does not include the Authority or the Commissioner;

relevant person means—

(a) in relation to a person who is or has been acting under the direction or

authority of the Authority—the Authority; or

(b) in relation to a person who is or has been a member of the police force—

the Commissioner; or

(c) in any case—the Minister.

(2) Except as required or authorised by this Act or by a relevant person, a person who

is, or has been, a prescribed officer must not, either directly or indirectly, make a

record of, or divulge or communicate, information acquired by reason of his or her

being, or having been, a prescribed officer, being information that was disclosed or

obtained under this Act.

Maximum penalty: $2 500 or imprisonment for 6 months.

(3) Where the Commissioner furnishes to the Authority a certificate certifying that the

divulging or communication of information specified in the certificate, being

information that has been disclosed to the Authority by a member of the police

force or obtained by the Authority from records of the police force, might—

(a) prejudice present or future police investigations or the prosecution of

legal proceedings whether in the State or elsewhere; or

(b) constitute a breach of confidence; or

(c) endanger a person or cause material loss or harm or unreasonable distress

to a person,

then, despite any other provisions of this Act, a person who is, or has been, the

Authority or a person acting under the direction or authority of the Authority must

not, either directly or indirectly, divulge or communicate any part of the

information except with the approval of the Commissioner or the approval of the

Minister given after consultation with the Commissioner.

Maximum penalty: $2 500 or imprisonment for 6 months.

9

(4) This section does not prevent a person who is or has been a prescribed officer from

divulging or communicating information disclosed or obtained in the course of an

investigation under this Act—

(a) in proceedings before a court, the Tribunal or the Commissioner in

respect of—

(i) an offence; or

(ii) a breach of discipline,

relating to a matter the subject of the investigation; or

(b) as required in proceedings under the Royal Commissions Act 1917; or

(c) as required by order of a court, the court being satisfied that there are

special reasons requiring the making of such an order and that the

interests of justice cannot adequately be served except by the making of

such an order.

(5) This section does not prevent a person who is or has been a prescribed officer from

whom information has been sought in the course of an investigation under this Act

from consulting—

(a) a legal practitioner; or

(b) some other person with the Minister's approval (which may be a

general approval or given in a particular case),

in relation to the matter under investigation.

(6) This section does not prevent a person who is or has been a member of the

police force whose conduct has been under investigation under this Act from

divulging or communicating particulars of the outcome of the investigation as

furnished or registered under section 36 (including any comments made by the

Authority when furnishing any of those particulars).

(7) Despite any other Act or law, a person who is or has been the Authority or the

Commissioner cannot be required to divulge information disclosed or obtained

under this Act in the course of an investigation except where such a

requirement is made—

(a) in proceedings before a court or the Tribunal in respect of—

(i) an offence; or

(ii) a breach of discipline,

relating to a matter the subject of the investigation; or

(b) in proceedings under the Royal Commissions Act 1917; or

(c) as required by order of a court, the court being satisfied that there are

special reasons requiring the making of such an order and that the

interests of justice cannot adequately be served except by the making

of such an order.

(8) If a person consulted under subsection (5) obtains information as a result of the

consultation that the person who initiated the consultation is (apart from that

subsection) prohibited from divulging or communicating, the person so consulted

must not divulge or communicate that information.

Maximum penalty: $2 500 or imprisonment for 6 months.’

10

3.5. Section 48 of the Police Complaints Act operates as a secrecy provision in respect of

people other than the Police Complaints Authority and the Commissioner. I formally

requested the Police Complaints Authority and the Commissioner of Police

voluntarily to produce all relevant information held by them in connection with the

disciplinary process to the Court. They both declined to do so.

3.6. The secrecy provision operates to prevent a person who is or has been a police

officer5 from divulging information acquired by reason of his or her having been a

police officer being information that was disclosed or obtained under the Act. Clearly

this prohibition was apt to prevent the disclosure by any of the police witnesses before

the Inquest of information that had been disclosed by them to the Internal

Investigation Branch or the Police Complaints Authority.

3.7. However, I took the view, with which Counsel for the Commissioner of Police did not

disagree, that the prohibition did not prevent such officers from providing the same

information they might previously have given to the Internal Investigation Branch or

the Police Complaints Authority in answer to a direct question before the Court,

provided that the question was not framed in a way that requested them to disclose

what they had provided in answer to inquiries made by the Internal Investigation

Branch or the Police Complaints Authority. In other words, if an officer had been

questioned by Internal Investigation Branch and asked a particular question as to steps

taken on the night of 25 February 2004, and the officer provided an answer, then

Counsel before the Coroner’s Court could ask the officer exactly the same question in

evidence and that officer would be obliged to answer the question and this would

involve no breach of section 48 of the Police Complaints Act. Thus there would be

no objection to eliciting answers from individual officers simply by asking those

officers questions which might yield the same information as was provided to the

Police Complaints Authority or the Internal Investigation Branch provided that the

question was not framed in such a way as to ask what they actually said to the Internal

Investigation Branch or the Police Complaints Authority.

3.8. That left open the possibility that I might have occasion to direct a witness to divulge

information disclosed under the Police Complaints Act pursuant to section 48(7)(c) of

the Act. However, I took the view that the tests required to be satisfied under that

section were never met. That section required me to be satisfied that there were 5 Excepting the Commissioner

11

special reasons requiring the making of an order and the interest of justice could not

adequately be served except by the making of such an order. The ability for the Court

to hear, at least in theory, the same evidence from witnesses before the Court as given

by those witnesses to the Internal Investigation Branch or the Police Complaints

Authority meant that it was difficult to satisfy the requirement that there be special

reasons requiring the making of an order. It seemed to me that the most likely special

reason would be that I was of the view that a witness may not have been providing a

truthful account to me and that that would afford a special reason to verify the account

to the Court by checking it against a previous account provided to the Internal

Investigation Branch or the Police Complaints Authority. In the circumstances that

situation did not arise. Although the accounts of some witnesses differed, I have felt

able to dispose of this matter without requiring production of previous accounts given

by those witnesses.

4. Public interest immunity

4.1. The material available to the Court before the commencement of the Inquest was not

such as would attract a claim for public interest immunity. However, from a very

early stage in the Inquest, Counsel for the Commissioner of Police raised the subject

of public interest immunity and foreshadowed that a claim would be made in relation

to some material. That was material which had yet to be provided by the

Commissioner of Police but was clearly thought by the Commissioner and those

advising him to be relevant to the Inquest.

4.2. Subsequently Counsel for the Commissioner of Police suggested that I look at the

relevant material privately. I resisted this suggestion preferring to conduct the Inquest

as publicly as possible and wishing to ensure that I saw nothing which could not be

publicly revealed. The Commissioner filed an affidavit sworn by Detective Senior

Sergeant Grant Garritty on 26 June 2007. This was an “open affidavit” in the sense

that no objection was taken to publication of the affidavit or any part of it. The

material the subject of the public interest immunity claim was described in paragraph

13 of that affidavit as follows:

‘During the later half of 2003 SAPOL received information from a registered human

source that HB was in possession of a revolver.

a. This information was documented and disseminated to Holden Hill police in hard

copy document for action.

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b. Informant Management Section/Human Source Management Section received no

further information as to any results or outcomes from the referral of the

information.’

4.3. I accepted the need to respect the public interest in the non-disclosure of the identity

of a “human source” or informant. The public interest in non-disclosure of the

identity of informants is well established and well known. The more difficult issue

would be the application of the second part of the well established principle for

dealing with claims of public interest immunity in the context of an Inquest: the so

called “balancing exercise” in which the Court is required to balance the public

interest in the preservation of the confidentiality of certain information against the

detriment that might be caused to the administration of justice if that information were

not to be available in the proceedings. That test is normally applied in an action, civil

or criminal, between parties. I am not aware of any authority upon the application of

the principle to an Inquest. The difficulty that I perceive is that the second part of the

test, namely the balancing of the detriment to the administration of justice is a

variable factor in normal civil or criminal litigation in that the detriment to the

administration of justice is measured by the forensic advantage that might be obtained

or lost if the material is produced or not produced to one or other of the parties. In an

Inquest, the purpose of which is to ascertain the cause or circumstances of specified

events, any material relevant to the circumstances surrounding the event in question is

relevant, and it is difficult to perceive any quantitative test which could be applied to

determine in a way analogous to the application of the test in civil or criminal

proceedings, the “forensic advantage” of the inclusion or non-inclusion of the

particular information.

4.4. Be that as it may, I resisted the need to pursue the identity of the informant on the

ground that it seemed to me to be irrelevant.

4.5. Late in the Inquest, when it was proposed to recall Detective Senior Constable Rohan

Crawford to give evidence, his Counsel pressed upon me the need to consider the

identity of the informant in order to better understand the position of Detective Senior

Constable Crawford who, it was said, had done certain things which could not be

disclosed without disclosing the identity of the informant. I briefly convened the

Court in camera and was informed during that session of the identity of the informant,

and was assured by Counsel for Detective Senior Constable Crawford that he had

13

carried out more investigations than he was able to reveal without disclosing the

identity of the informant. On the basis that Detective Senior Constable Crawford may

have done more than he was able to disclose, I excused him from further attendance,

having taken the view that the matter could not further be pursued because to do so

would require the divulgence to a wide group of people of the identity of the

informant and that this exercise would not materially assist me in an analysis of the

circumstances leading to Mr Wilson’s death, but would only serve to prove one way

or the other whether Detective Senior Constable Crawford had in fact done more than

was apparent on the face of the evidence both oral and documentary as it then stood.

4.6. Detective Senior Constable Crawford’s evidence was relevant to the Dreelan PIR and

the information contained in paragraph 13 of Detective Senior Sergeant Garritty’s

affidavit6. All references to the evidence of Detective Senior Constable Crawford in

this finding should be read against the background that I must accept that there were

further steps taken by him than those which are apparent on the evidence in pursuing

those two matters. However, the results of those investigations, so far as they are

relevant to the circumstances leading to the death of Mr Wilson, will be apparent on

the face of these findings. There were admitted deficiencies in those investigations. I

am unable to attribute them to Detective Senior Constable Crawford for the reasons I

have already stated, however that does not mean that there were not deficiencies.

Indeed, as will be apparent in due course, such deficiencies were acknowledged by

Deputy Commissioner Burns in his evidence. The deficiencies must be regarded as

attributable in a “corporate” sense to South Australia Police, and should not be taken

in this finding, as referable to Detective Senior Constable Crawford except where

specifically appears.

5. The earlier offending of HB

5.1. The evidence revealed that in the early hours of Sunday, 30 March 2003, HB was

involved in an altercation with an unknown person at McDonald’s on West Terrace,

Adelaide. At about 5:30am he returned to the McDonald’s in possession of a long

barrelled pump action firearm. He confronted a number of patrons, waving the

firearm at them and apparently looking for the person with whom he had the earlier

altercation. He was shouting that he was going to kill that person. He pointed the

firearm at a number of people inside the restaurant while holding his finger on the 6 Exhibit C40

14

trigger and shouting that he would kill those involved. A security guard stepped in

and moved HB from the restaurant to the car park where he continued to wave the

firearm around at people. He was arrested later that day at his home address in Duthie

Street, Hillcrest. Although the gun was not located at that time it was later handed to

police, apparently by HB’s father.

5.2. It was discovered by police that the firearm was stolen although it was not alleged that

HB was the thief. HB did not have a licence to possess a firearm. He had just turned

17 when this happened.

5.3. On 22 June 2003, despite being on bail in relation to the incident previously

mentioned, and despite that bail being conditional upon HB not leaving his home

except for the purposes of attending school, for the purpose of attending his family’s

mosque, and for the purpose of seeing his solicitor, HB was arrested at approximately

11:30 pm on 22 June 2003, after having been observed doing burn-outs in Gouger

Street and having been found to have a Samurai sword under the driver’s seat of his

car.

5.4. On 8 July 2003, HB appeared before the Youth Court and was sentenced for the

offences of threatening a person with a firearm (two counts), possessing a firearm

with intent to commit an offence, possessing a firearm without a licence, carrying an

offensive weapon, giving a false name and address, failing to comply with a bail

agreement, and unlawful possession. HB was sentenced to four months detention

which was suspended on the condition that he enter into an obligation with the Court.

The length of that obligation was 18 months. The paramount condition of the

obligation was that he be of good behaviour for that period. In addition to that, he

was to reside at his Duthie Street home address. Condition 5 of the obligation

prohibited him from possessing or carrying any firearm or offensive weapon

including knives. The obligation was acknowledged by HB on that day.

6. Police warnings in relation to HB

Some time around June 2003, warnings were placed onto the Police Information

Management System (“PIMS”) which is a computerised information management

system allowing for the sharing of information within South Australia Police7. Those

7 Exhibit C10, affidavit of Chief Inspector Grant Moyle, paragraph 6

15

warnings related to HB. They came mostly from ancillary reports. Such reports come

to generated, and the information therein transferred to the PIMS system, in

accordance with a process described in the affidavit of Deputy Commissioner Burns8

and the affidavit of Senior Constable Allan Ziegler9. The warnings which were

inserted on the PIMS system in June 2003 included “may be armed”, and

“psychological/psychiatric disorder”.

7. The murder of Christopher Wilson

7.1. I will now briefly describe the events immediately preceding the shooting of

Christopher Wilson. These events occurred on the night of 27 and the early hours of

the morning of 28 February 2004. 27 February 2004 was a Friday. That night,

Christopher Wilson, James McAinsh, Ryan Williams, Justin Williams and Mark

Wilson gathered together at the home of Mark Wilson. They were drinking alcohol

and talking about the events of the previous Wednesday night when they had had an

altercation which will be described in more detail later.

7.2. According to James McAinsh the idea arose of walking around to Duthie Street which

was nearby, and “sus out the house”10

which they believed the persons involved in the

earlier altercation might live in or frequent. Ryan Williams gave an account that it

was in the back of his mind that they might find the men who had been involved in

the incident on Wednesday night and “beat them up if we found them”. Ryan

Williams armed himself with a broken off golf club shaft. Christopher Wilson was

drinking from and took with him a 750 ml bottle of Coopers Pale Ale beer.

7.3. There is a park on one side of Duthie Street opposite the house that the men were

interested in. They sat in the park in a position just south of two large drains which

are located in the centre of the park. They remained there for a little while, perhaps

half an hour, looking at this house. After that period they decided to walk back to

Mark Wilson’s house.

7.4. The question arises: what was the motivation of the group in attending at Duthie

Street that night. It was suggested by some members of the group who gave evidence

at the Inquest that they decided to attend the scene because they believed that police

8 Exhibit C34

9 Exhibit C25b

10 Transcript, page 113

16

had not taken sufficient action following a report made by them about the incident

which occurred on the Wednesday night. Other members of the group, such as Ryan

Williams, clearly had vengeance in mind. On the whole of the evidence, it is not

possible to conclude that the group acted in concert with a common purpose to seek

vengeance. It is clear that some members of that group may have had that purpose.

Other members may have had no particular purpose other than curiosity. It was

forcefully submitted by the Commissioner of Police that their behaviour in attending

at the scene on that night was foolhardy, knowing that they might encounter a person

who they knew to possess a firearm, and a willingness to use it. Whether the

behaviour was motivated by an intention to seek vengeance, or was mere bravado by

relatively young men filled with alcohol and with some idle hours to fill, or whether

the motivation was that the locality was relatively close to the home of Mark Wilson

and the group was keen to carry out some form of reconnaissance because of a

concern that Mark Wilson might encounter HB again, is not clear. I agree that the

decision on the part of some members of the group to arm themselves with objects

such as golf club shafts was foolish in the extreme. However, not all members of the

group equipped themselves in that way. It was not clear that all members of the group

were aware that some members of the group were armed. The most that can be said is

that some members of the group acted in a foolhardy manner, some in an extremely

foolhardy manner, and others in a relatively unexceptionable manner.

7.5. As I have said the group decided to leave the area opposite the house they thought to

be occupied by their protagonists from the previous Wednesday night. They decided

to return to Mark Wilson’s house and walked across the park and onto Duthie Street.

It will be recalled that the group consisted of Justin Williams, Ryan Williams,

Christopher and Mark Wilson and James McAinsh. As they were walking along

Duthie Street a car drove into Duthie Street. It was a white VK Commodore. A

passenger emerged from this vehicle. It was HB. Mark Wilson walked up to HB and

punched him in the face causing him to fall to the ground. Mark Wilson apparently

recognised HB as the person who had discharged a firearm on the preceding

Wednesday night, hitting his brother in the leg.

7.6. HB then ran away in the direction of his home which was approximately 60 metres

away. While in his home, he obtained his gun, which was loaded, and returned to the

area where the car and the group of young men were located. That group was then

17

engaged in a conversation of a relatively calm nature. HB walked up to Justin

Williams and pointed the gun at his face. HB attempted to fire the gun but fortunately

for Justin Williams, it did not discharge. HB then pointed the gun at Mark Wilson,

telling him to get on his knees and to apologise. Mark Wilson complied. HB fired a

shot into the ground in front of Mark Wilson and then fired at least one more shot in

the direction of Mark Wilson one of which struck him in the left arm.

7.7. When HB began firing the gun, the other males in the group began to scatter.

Christopher Wilson started to run in an easterly direction on Duthie Street. HB fired

his gun at Christopher Wilson, striking him in the back as he was running away. That

shot caused Christopher Wilson to fall to the ground. HB then walked towards him,

stood over him and fired two further shots from close range into his head. Shortly

after this, HB used a mobile telephone to dial 000, and report the incident and request

the attendance of an ambulance. An ambulance attended, and police attended. HB

was then arrested.

8. The first shooting incident involving Christopher Wilson

8.1. On Wednesday, 25 February 2004 at around 11:00 pm Christopher Wilson and four of

his friends departed from the home of Mark Wilson to attend the OG Hotel to play the

poker machines. They were being driven in a Magna motor vehicle owned and driven

by James McAinsh. Ryan Williams was a passenger in the front seat of the vehicle.

Mark Wilson (the brother of Christopher Wilson) was in the rear passenger side seat,

Dylan Connelly was in the middle rear seat and Christopher Wilson was seated in the

rear driver’s side seat. As I have already said Christopher Wilson was 23 years old at

that time. His friends were all of around the same age.

8.2. It appeared that Mark Wilson’s “wheelie bin” had disappeared from his home and it

was thought that it may have been stolen. The evidence suggests that at least part of

their purpose as they drove away from Mark Wilson’s house that night, in addition to

travelling to the OG Hotel, was to keep an eye out for the missing wheelie bin. This

may have accounted for the fact that the group took a wrong turn and ended up in

Duthie Street at Hillcrest. The western end of Duthie Street is a cul-de-sac and it was

in this direction that the vehicle containing the five men travelled. Duthie Street runs

parallel with Flinders Street and they are separated by a narrow strip of “park” or

vegetation. It was that narrow strip which some of the group visited on the following

18

Friday night on the occasion of the murder of Christopher Wilson. On the northern

side of Duthie Street there are a number of domestic dwellings, including that of HB’s

family.

8.3. It may be that James McAinsh had turned into Duthie Street having mistaken it for

Flinders Street. In any event, at the western end of Duthie Street the Magna executed

a manoeuvre described by James McAinsh in his evidence as a “five-point turn”. As

the vehicle moved along Duthie Street, now proceeding in an easterly direction, some

of the men in the car noticed some people standing in front of a house in Duthie

Street. They did not pay much attention to this at the time. Some of them gave

evidence that they noticed a car parked at that address facing towards the road and

that there was a light on at the house. The group in the Magna left Duthie Street and

travelling briefly on Hawkins Avenue, turned into Flinders Street. While travelling

on Flinders Street they noticed a car coming up behind them. The car began to flash

its lights at them and so James McAinsh executed a U-turn at the next roundabout and

stopped his car facing in the opposite direction and alongside that other vehicle. The

evidence suggested that the rear doors of each of the cars were approximately

adjacent to one another, the vehicles facing in opposite directions.

8.4. Two males alighted from the other vehicle which was described subsequently by

some of the men in the Magna as a black or dark coloured BMW. The males from the

BMW were yelling something about the men in the Magna being in “their street” and

were yelling for the group to “keep out” of “their street”. Ryan Williams and Mark

Wilson alighted from James McAinsh’s car and approached the people from the

BMW, meeting them in the space between the two vehicles. At this stage,

Christopher Wilson had opened the rear right door of the Magna but had not alighted

from it. One of the males from the BMW, the passenger, was HB. It seems that HB

enquired in an aggressive fashion what the men in the Magna had been doing in his

street. It may be that they responded that they were looking for a stolen wheelie bin

but had made the wrong turn. HB produced a revolver. He was told by his

companion to put it away but he did not do so. He fired a shot from the revolver

apparently in the direction of the road surface.

8.5. Although Christopher Wilson did not realise it immediately, the shot fired by HB had

ricocheted off the road surface and hit him in the right leg below the knee on the calf

muscle. As soon as the shot was fired, Mark Wilson and Ryan Williams quickly re-

19

entered the Magna and James McAinsh drove away from the scene. They were not

followed by the BMW and had no further contact with it.

8.6. As they drove away Christopher Wilson felt something warm and wet on his leg and

realised he was bleeding. He told the others in the car and they travelled to a nearby

BP Service Station where they pulled in and had a look at Christopher Wilson’s leg.

It was not bleeding profusely and Mr Wilson did not consider that it required medical

assistance. Christopher Wilson did not complain of being in great pain and did not

suggest that he see a doctor or be taken to a hospital.

8.7. At that point, the men in the Magna discussed what ought to be done next. The

subject of going to the police was raised. The evidence of James McAinsh, Ryan

Williams and Dylan Connelly suggests that Christopher Wilson was not enthusiastic

about reporting the matter to the police, although he was not completely resistant

either. James McAinsh gave evidence that it was he who raised the topic of reporting

it to the police. It appears that James McAinsh also mentioned that this would be

necessary if Christopher Wilson were later to pursue a criminal injuries compensation

payout as a result of the wound. In the result, James McAinsh took responsibility for

the decision and said that they were going to the police and that is what happened11

. I

should mentioned that neither Ryan Williams nor Dylan Connelly gave evidence of

being aware of a discussion about criminal injuries compensation. Their motivation

for going to the police was the simple fact that they had been shot at and that a person

was in possession of a gun and prepared to use it. The group then attended at the

Holden Hill Police Station which was quite close by. They were asked why they did

not ring the police from the BP Service Station and their response was that the Holden

Hill Police Station was within five minutes drive.

8.8. They travelled to the Holden Hill Police Station via Flinders Street and past Duthie

Street where they thought the BMW had come from in an effort to see if it was the

same vehicle as that which had followed them and been involved in the encounter in

Flinders Street. They saw nothing. Some of the men had different recollections in

this regard. For example, James McAinsh did not think that they went via Flinders or

11

Transcript, page 87

20

Duthie Street12

. Other members of the group had a different recollection and on

balance I think it more likely than not that this did occur.

8.9. Dylan Connolly’s account of the events of the evening of 25 February 2004 provides

a good summary. He recalled that James McAinsh was driving, Ryan Williams was

in the front, he (Dylan Connelly) was in the middle in the back, Mark Wilson was on

his left and Christopher Wilson was on his right13

. He said that they left to go and

play the poker machines at the OG Hotel14

. He related the story of the wrong turn

down Duthie Street15

, and said that they noticed one house with the lights lit up and a

car reverse parked in the driveway16

. Dylan Connelly’s account of the confrontation

with the BMW appears at T1377-T1379. He stated that when the vehicle stopped

“these blokes jumped out, like rambling” and there were two of them. Mark stepped

out of the Magna and Dylan Connelly jumped out behind him. The following is a

useful summary of what happened next:

‘They were yelling obscenities and stuff, saying 'What the fuck are you doing in that

fucking street? Fuck away from that house' etc. That's when I stepped out. The two

boys were both on the driver's side of the car and we're just at the boot on the other side

of our car and you see one of them trying to do something with his belt and the other one

is just going 'No, man, no, put it away, man. What the fuck are you doing?'. Because he

tried to push it back into his mate's belt, he pulled it out. I think we both sort of stood

there, shocked for a second. He's pulled out this massive gun and he's still just yelling

and threatening us about the house. We were just trying to get back into the car, and just

as I am getting back into the car I heard a pop. We jumped back in the car, with Mark

right behind me and we have gone.’17

8.10. Dylan Connelly made it plain that as soon as he saw the gun he moved to get straight

back into the car. When he heard the “pop” sound he was still outside the car but was

just putting his head down to get in. Mark Wilson was right behind him. Once they

got into the car it drove off straight away18

.

8.11. Dylan Connelly provided some evidence about what knowledge any members of his

group had of the identity of the shooter. He said that he thought that Mark Wilson

said something to one of the occupants of the BMW when they first stepped out of the

12

Transcript, page 87 13




Transcript, pages 1375 – 1376 17


Transcript, page 1380

21

car along the lines of “I went to school with your brother”19

. The occupant of the

BMW did not respond. They were not listening to Dylan and Mark because they were

just shouting20

. Dylan Connelly also said that after the shooting incident he did not

believe that Mark Wilson further discussed the identity of the two individuals in the

BMW. He said that he did not believe that either he or any of the other members of

the group discussed the identity of this person with Mark Wilson during the trip to the

Holden Hill Police Station21

even though that would have been important information

to provide to the police.

9. The attendance of Christopher Wilson and others at Holden Hill Police Station

on 25 February 2004

9.1. The evidence is clear that formal written statements were taken by police officers at

the Holden Hill Police Station that night or in the early hours of the following

morning from Christopher Wilson, James McAinsh and Dylan Connelly. No

statement was taken from Ryan Williams that night, nor from Mark Wilson.

9.2. James McAinsh

James McAinsh said that four members of the group entered the police station and

spoke to a person at the front counter who he believed to be a uniformed police officer

by the name of Wilson. It is apparent from the totality of the evidence that he was

wrong in this – the officer was Senior Constable Redding. He said that the men

walked into the Holden Hill Police Station and said words to the effect “Our mates

been shot he has a gunshot wound”. They said, “we know where this person is he has

just pulled out a gun on us and shot it”. The police officer said words to the effect of

“hang on what do you reckon happened?” with, according to Mr McAinsh, a smirk on

his face. Mr McAinsh took this to indicate scepticism or disbelief22

. At this point

Ryan Williams walked out of the police station23

. According to James McAinsh, the

wound was shown to the officer at the front desk. James McAinsh also said that he

gave all of the information he had about the events of the night and did not hold

anything back24

. He was asked whether he provided to anyone at the Holden Hill

Police Station information to the effect that he knew either the passenger or the driver

19

Transcript, page 1381 and Transcript, page 1398 20





Transcript, page 97

22

of the vehicle. He answered that he did not do so because he did not know them. He

said:

‘Over the next few days names were mentioned around the scenery. I can't remember. I

mean the other guys may have known them; I didn't know them prior. I went to a totally

different high school, totally different scenery. I've never seen them before.’25

James McAinsh also said he did not remember any member of the group saying that

they knew who the shooter was26

. He said that no one at the Holden Hill Police

Station looked at his car that night. He remembered that very clearly because his car

was unregistered27

.

9.3. It is notable that James McAinsh said that when the group entered the police station

they were all talking at once28

.

9.4. Certain aspects of Mr McAinsh’s account are clearly not correct. These include the

identification of the officer at the front counter as a uniformed officer called Wilson.

There was no uniformed officer by that name at the counter at that point.

Subsequently, a uniformed police officer by the name of Luke Wilson attended at the

Holden Hill Police Station at the request of Sergeant Mickan and took a statement

from Dylan Connelly. However, Constable Luke Wilson did not have contact with

any of the witnesses apart from Dylan Connelly while he was at the Holden Hill

Police Station29

. Mr McAinsh’s recollection that the wound was shown at the initial

presentation at the counter does not seem to accord with the evidence of other

witnesses either. Furthermore, it is difficult to see how Christopher Wilson could

have demonstrated the leg wound while on the opposite side of the counter from any

of the police officers. Mr McAinsh himself acknowledged this and suggested that the

police officer may have come around to their side of the counter. I consider this to be

unlikely. Mr McAinsh noted that he had given a number of interviews about the

events of that night and the following Friday night over the ensuing couple of

months30

. As a result his recollection may have become confused in some respects.

However, I have no reason to doubt his basic position that the group conveyed at a

25






Transcript, page 96

23

very early stage to the officer behind the counter that one of their number had been

shot by a person with a gun.

9.5. Dylan Connelly

Dylan Connelly gave evidence. He said that there was no discussion of ringing the

police immediately after the incident because the police station was ‘straight up the

street”31

. He was asked whether there was any thought of getting medical attention

for Christopher Wilson and his response was that he doubted that was considered

because of “..the way we are. If it’s not life threatening or anything we never

bother.”32

Dylan Connelly also shed some light on the question of whether the

McAinsh vehicle returned to Duthie Street on the way to the police station. He

referred to driving past the other side of the park which separates Duthie Street from

Flinders Street. I infer that the occupants of the McAinsh vehicle drove parallel with

Duthie Street and attempted to see if they could spot the BMW through the park that

separated Duthie Street from Flinders Street33

. Upon arrival at the Holden Hill Police

Station, Dylan Connelly stated that it was he and Christopher Wilson who entered the

police station and he was not certain if any other members of the group came in at that

stage. He was aware that James McAinsh came into the police station at a later point

when he found the bullet fragment on the back floor of the car where Christopher

Wilson had been sitting34

.

9.6. He did not recall the actual words that were used to the officer at the front counter

but:

‘…it was along the lines of “My mate’s been shot” or Chris would have said “I’ve been

shot”, but that’s it, I don’t know.’35

Interestingly, Dylan Connelly also had a recollection that Christopher Wilson showed

the wound on his leg at the front counter stating “I’m sure he did but I truly can’t

recall”36

.

9.7. Dylan Connelly said that after a period at the front desk he and Christopher Wilson

were taken to a small interview room. His evidence is consistent with entering that

31







24

interview room with the first unformed officer to whom they initially spoke at the

front counter37

.

9.8. Dylan Connelly said that he was shocked at how the police were treating them and by

their words or conduct suggesting that the wound looked like nothing and didn’t look

like a gunshot wound. He even said that some of the plain clothes officers had a

chuckle38

. Dylan Connelly said that once he and Christopher Wilson had been taken

into the interview room, a police officer started to take a statement but because

Christopher Wilson and Dylan Connelly were both telling the story the police officer

said “we had better split you up and take two separate statements” and at that point

Dylan Connelly left that interview room39

.

9.9. Dylan Connelly also stated quite emphatically that he made an offer to a police officer

to take them to the house with the lights on from which they thought the BMW had

come. He thought that this was an offer made at the front counter of the police station

upon arrival. He also referred to showing the address where the house was located by

reference to a street directory40

.

9.10. It is significant that Dylan Connelly also recalls seeing the bullet fragment which was

taken from the back of the Magna into the police station by James McAinsh. He said

that when he saw the fragment he believed it had been handed in at the desk

(presumably by James McAinsh) and then had been brought into the interview room

occupied by him and Christopher Wilson. Dylan Connelly was positive that he saw

the fragment and commented that it looked very damaged from having ricocheted41

.

Dylan Connelly said that although the projectile was mangled he still thought that it

was a bullet because he thought it was made of lead. He said that he saw it when it

was brought in while he and Christopher Wilson were still in the interview room42

.

When it was brought in it was inside a bag. It was brought in by a policeman and the

officer who brought it in or another officer said something like “that doesn’t look like

a bullet”43

. He confirmed that it was in a bag at this point44

. He said:

37









25

‘I just remember one of them saying that “that doesn't look like a bullet”, and I'm saying,

“well, if that ricocheted off the ground first, then that's probably what it would look

like”.’45

9.11. Dylan Connelly could not recall either himself or Christopher Wilson telling the

officers a name of who the perpetrator might have been46

. Dylan Connelly said that

he circled the location of the Duthie Street address on a map (I presume he meant a

street directory) and said to the police officer “I could take you there right now”47

.

Dylan Connelly said that he did not hold any information back from the police that

night48

. He said that he did not think that the police ever suggested to him that the

episode was a road rage incident or anything like that49

. He was asked whether he

noticed any particular reaction from the police officer or officers when he said that the

weapon which was involved was a pistol or a revolver. He said that this did not

produce any particular reaction from the police; it did not cause them to prick up their

ears50

. Dylan Connelly discussed the motivation for reporting the matter to police.

He said that he thought: “lunatic’s running around with a gun, you know what I mean,

like, do anything about it, then nothing is going to happen.51

”

9.12. Senior Constable Michael Redding

Senior Constable Michael Redding gave evidence at the Inquest. He is a police

officer of 33 years standing. He said he was at the front counter of the police station

when the young men came in. He recalled that two of them came to the counter and

he was aware that there were another two in the foyer that were connected with the

two at the counter. The two at the counter were Christopher Wilson and Dylan

Connelly52

. He said that he spoke with Christopher Wilson and Dylan Connelly at the

counter for a period of approximately 10 to 15 minutes before moving with the two of

them into a separate interview room. He said that while he was in the interview room

with Christopher Wilson and Dylan Connelly, Detective Mark Wilson came in and

shortly after that, at Senior Constable Redding’s instigation, Dylan Connelly was

45









26

required to leave the interview room. He thought that his interview with Christopher

Wilson took 45 to 50 minutes53

.

9.13. Senior Constable Redding said that he had just started a nightshift when the men came

in. He said “Christopher Wilson wanted to report a road rage incident and that’s what

he termed it as”54

. According to Senior Constable Redding, Christopher Wilson

presented at the front counter in quite a normal manner – “not traumatised, no hint of

anything that one would – well I would have equated with having received a

wound”55

. According to Senior Constable Redding, Christopher Wilson told him

about the black BMW, the “Afghan type blokes” and that when they stopped in

Flinders Road and two of their number had left their car, Christopher Wilson who was

seated in the back of the car saw one of the “Afghan blokes” pull something out of his

pants. A fight started between the driver of the BMW and the passenger of the BMW

while they were arguing with the people from Christopher Wilson’s car. Senior

Constable Redding said that Christopher Wilson described the thing that had been

pulled out of the person’s pants as looking like a bat or baseball club. He said “it

started off with a club – like a bat, or like a club, but then it got defined quickly to a

baseball bat, ‘could have been a baseball bat’”56

. Senior Constable Redding said that

it was at that point that he invited Christopher Wilson and Dylan Connelly into an

interview room.

9.14. He said that the story developed further in the interview room. Senior Constable

Redding went through the story again. He said that as they worked through the story

Christopher Wilson elaborated on the incident and said that he thought he heard a pop

like a slug gun. Senior Constable Redding then asked Christopher Wilson something

to the effect “was the baseball bat a firearm?” to which Christopher Wilson replied

that it could have been, it may have been a bigger gun57

. Senior Constable Redding

said that as this conversation took place, Sergeant Mickan was nearby and was

occasionally standing inside the doorway of the interview room apparently listening.

He said that because the situation had escalated to the point where a firearm was

involved his reaction was to contact the Criminal Investigation Branch (“CIB”)

because of the serious nature of the offence. He would also take a detailed statement

53






27

from Christopher Wilson58

. Senior Constable Redding said that he was perplexed by

what he insisted was Christopher Wilson’s nonchalant attitude to the event. He said

that at this point the wound had still not been mentioned59

.

9.15. According to Senior Constable Redding, Christopher Wilson elaborated further and

told him that as he was about to get out of the car he felt something hit his leg and that

he leant down and felt something warm and wet and “that’s when I had a look at what

he was alleging to be a wound in his leg”60

. This had not been mentioned

previously61

. Senior Constable Redding said that at this point he reassessed

Christopher Wilson. He said that there was no blood on Christopher Wilson’s hands

and no blood or soiling around his shoes or socks. Senior Constable Redding

described the wound as looking like “a breaking of the skin like a cigarette burn”62

.

9.16. Senior Constable Redding said that it was at about this time that Detective Mark

Wilson entered the interview room. He said that he was a little bit shocked by it all

because the wound had been “revealed so late from the initial inquiry at the front

counter about a road rage incident”63

. Senior Constable Redding said he was not

satisfied with what Christopher Wilson was telling him, he did not think that it added

up and did not think that there was a full disclosure of the events or that Christopher

Wilson was being frank with him.

9.17. Senior Constable Redding was asked at what stage he directed Dylan Connelly to

leave the interview room. He was unable to be certain about that. However, he

explained that his decision to send Dylan Connelly was based on his feeling that the

story had changed “so many times” that it was necessary to separate Dylan Connelly

and Christopher Wilson64

.

9.18. Senior Constable Redding was aware that statements were being taken from some of

the other members of Christopher Wilson’s group while he was taking his statement

from Christopher Wilson65

.

58



Transcript, pages 314-315 61






28

9.19. Senior Constable Redding said that Detective Mark Wilson left the interview room

and then returned to it a short time later with Detective Green. Detective Mark

Wilson was holding a plastic bag containing what appeared to be a fragment of a

projectile66

.

9.20. Senior Constable Redding said that he suspected that Christopher Wilson and the

other members of his group may have known their assailants67

. When Senior

Constable Redding finished taking his statement from Christopher Wilson he let him

out into the foyer which was empty. Somewhat dramatically, he described

Christopher Wilson as being met by a “shadowy figure” just outside the front of the

police station68

. He assumed that witness statements were in preparation at that time.

At that stage he could no longer see any sign of the CIB members.

9.21. Senior Constable Redding prepared a Police Incident Report (“PIR”). That document

appears as GM1 to an affidavit of Inspector Grant Moyle sworn 26 June 2007 which

was admitted as Exhibit C10. Hereafter, I will refer to exhibits to this affidavit simply

by their exhibit name. The PIR states that at 1220 hours on 25 February 2004 at

Flinders Road, Hillcrest, Christopher Wilson was with his brother and three others

and were challenged by the occupants of a BMW of unknown registration. A

passenger of the BMW got out and fired a shot from “a weapon of some sort, possibly

slug gun”, wounding Christopher Wilson in the lower right leg. The report states that

Christopher Wilson and two witnesses attended at Holden Hill Police Station about 30

minutes after the incident and that statements were obtained from all. It states that

Holden Hill CIB members Detective Wilson and Detective Green were “advised and

assessing for dayshift follow-up”. The PIR continues:

‘Nil further information on suspect vehicle or suspects. Appears this stage that the

suspect vehicle may be associated with person/s living in Duthie Street Hillcrest.

Attached is a copy of possible suspects, HB and HB’s brother, Duthie Street, Hillcrest,

but this info is an educated guess. Nil evidence to link these suspect names with this

incident this stage.’

The narrative goes on to explain that Christopher Wilson was advised to re-attend at

the police station for a photograph to be taken of his wound. It also states that part of

a projectile was obtained from the interior of the car the victim was in and that it had

66




29

been booked in as an exhibit. The PIR was first raised at 2350 hours on 25 February

2004. It was entered by Senior Constable Redding at 0117 hours on 26 February

2004. The only other pertinent information from the PIR was that it contained the

names, addresses and ages of Christopher Wilson, Dylan Connelly, James McAinsh

and Mark Wilson.

9.22. Senior Constable Redding said that the information in relation to HB’s brother and

HB was provided to him by either Sergeant Mickan or Probationary Constable

Crawford, more likely the former. Senior Constable Redding acknowledged that he

was aware when he finished with the PIR that Christopher Wilson had changed his

description of the gun to something which may have been bigger than a slug gun and

yet he completed the PIR without changing the reference to a slug gun69

. He had no

explanation for this.

9.23. Senior Constable Redding thought that the information provided to him as the result

of computer searches carried out by others, included the names of HB and HB’s

brother as possible persons of interest. He thought that this included a reference to

HB having a criminal record which included attempted murder70

. This was incorrect,

there was no such reference on HB’s record. Senior Constable Redding said that the

record of attempted murder which he believed to be part of HB’s record had firmed

up his view that a wounding had indeed happened71

. This is extraordinary. It should

have been obvious to him that Christopher Wilson had a wound – by that stage he had

actually seen it. To suggest that something on HB’s criminal record caused him to

feel safer in concluding that there had been a wounding when there was physical

evidence of a wound is most peculiar, particularly given that the information said to

be in HB’s record, namely attempt murder, did not appear in his record (at that stage)

at all.

9.24. Senior Constable Redding stated that he had been in the interview room for a

substantial amount of time with Christopher Wilson before there was mention of a

firearm and wounding72

. Senior Constable Redding acknowledged that he never

conveyed to Detective Senior Constable Green the name of a suspect or a person of

69





30

interest73

. He said that he never saw Probationary Constable Crawford look at

Christopher Wilson’s leg at the front counter74

. Senior Constable Redding

acknowledged that there was no reference in the statement he took from Christopher

Wilson, Exhibit GM29, to a report of road rage75

. He explained this by saying that

the road rage “basically paled in significance” as the matter escalated to an unlawful

wounding.

9.25. Senior Constable Redding was asked how it might have been that a projectile from a

slug gun had sufficient power to ricochet off the ground or some other object and hit a

person with a sufficient amount of force to cause a wound similar to that on

Christopher Wilson’s leg. He acknowledged that some slug guns are “pretty

powerful” particularly those of a high calibre76

.

9.26. Sergeant Glen Mickan

Sergeant Mickan is a sergeant of police. He gave evidence at the Inquest. He was on

duty with Senior Constable Redding and Probationary Constable Crawford in the

Holden Hill Police Station on the night of 25/26 February 2004. He was not

requested to make a statement about the events of that night at any time proximate to

those events. The first time he was asked to recall the matter in any detail was when

he was questioned by Internal Investigation Branch in early 2006, some two years

after the event.

9.27. Sergeant Mickan said that he recalled a group of people entering the police station

during his shift that night and that Senior Constable Redding went to the front counter

to greet them77

. Shortly after Senior Constable Redding had spoken to them Sergeant

Mickan had a conversation with Senior Constable Redding from which he learnt that

Senior Constable Redding was taking a report from a member of the group and that

some other members of the group had witnessed the event. At that point Sergeant

Mickan decided that his staffing was not sufficient to deal with the matter. Sergeant

Mickan understood the event to have been an assault, although he became aware

either on the first occasion he spoke to Senior Constable Redding about the incident

73






31

or the second occasion that a firearm may have been involved78

. Because further staff

were required he contacted Sergeant Tuk who was in charge of patrols and requested

that he provide officers under his control to assist. This happened very quickly. The

assisting officers were Senior Constable Peter Cox and Constable Luke Wilson.

Sergeant Mickan thought that they arrived within five minutes of Senior Constable

Redding entering the interview room79

.

9.28. Sergeant Mickan said that he recalled that when Constable Wilson and Senior

Constable Cox arrived he was speaking to Senior Constable Redding who was

informing him that the complainant’s story was changing and that he was indicating

that he had been shot with a firearm of some sort, possibly a slug gun, and that he had

been hit in the leg80

. Sergeant Mickan said that when he learnt that the matter was a

firearm incident, he then contacted the CIB because the incident was of a serious

nature81

. He said that he spoke to either Detective Wilson or Green by telephone and

explained briefly to them that they had an incident involving a firearm and a road rage

type incident and that he wished them to come down and look at the situation82

. He

believed that at that point he was aware of the location of the event, the involvement

of a particular type of vehicle and of the offender being from a particular ethnic

group83

. Sergeant Mickan said that, armed with this information, he directed

Probationary Constable Crawford to start running some computer checks on this

information84

. His recollection was that this search started prior to Detectives Green

and Wilson attending85

. Prior to the attendance of the CIB officers the computer

searches conducted by Probationary Constable Crawford had come up with a person

of interest or persons of interest by the name of B. When the CIB officers arrived,

Sergeant Mickan informed them of the details of this. He told them that Senior

Constable Redding was speaking to the victim and that there were people waiting in

the front office that were part of the group. Two other statements were being taken by

Senior Constable Cox and Constable Wilson. He said that he definitely informed

them of the detail generated from the computer searches86

. Those computer searches

78










32

as detailed by Sergeant Mickan to the CIB officers included an address, a name of a

person of interest that lived at that address and the fact that the person had a car which

was similar to that described by the group in the police station87

. Sergeant Mickan

said that he conveyed this information to both Detectives Wilson and Green together.

9.29. Sergeant Mickan said that from that time on it was “the CIB’s call” as to how the

matter would be handled. He said that at the point when the CIB arrived and were

briefed, they took over the investigation and it was under their direction that all

further inquiries and reports were undertaken88

.

9.30. Sergeant Mickan said that Detectives Green and Wilson decided that his staff should

finish taking the statements and then pass it on for allocation the following morning

by the Crime Management Unit. He agreed with that decision89

.

9.31. Sergeant Mickan gave evidence that he “vetted” the PIR that was produced by Senior

Constable Redding and the statements produced by Senior Constable Cox and

Constable Wilson later in the morning before despatching the investigation to the

Crime Management Unit for allocation in the morning.

9.32. Sergeant Mickan believed that the information which he had available to him from the

computer searches that morning included a registration number for a black or a dark

BMW90

.

9.33. Sergeant Mickan said that on the night he had the feeling that this was not a random

incident. He said that he formed that view because of the information coming from

Senior Constable Redding that the story and details were changing and had changed a

number of times. He formed the view that evidence was not freely being given by the

witnesses and that they knew who the person was and exactly where he lived91

.

9.34. Sergeant Mickan adhered adamantly to his position that the names of persons of

interest, namely the B’s, was given to the CIB detectives that night92

.

87







33

9.35. It was put to Sergeant Mickan in cross examination that one of the computer checks,

namely a check as to vehicle details, was not done, according to other evidence before

the Court, until a time after the CIB officers had left the building. Sergeant Mickan

suggested that this may be explained by the possibility that he was operating another

computer nearby in the police station and gained some of the information in that

manner and then gave it to the CIB officers93

. However, he admitted that he had no

clear recollection about this.

9.36. On the subject of the responsibility of the future conduct of the investigation Sergeant

Mickan said:

‘The fact is that CIB were called in, it then became their responsibility to investigate it.

It brings to mind if you go to an armed hold-up and CIB are called; because the

statements haven't been taken by all the witnesses, do CIB sit back and do nothing until

those statements have been provided? I don't think so. I think it's clearly a case of once

CIB are there, they are responsible.’94

9.37. Probationary Constable Tina Crawford

Tina Crawford gave evidence at the Inquest. She was a probationary police constable

working at Holden Hill Police Station in February 2004. She left the police force later

that year and is no longer a serving police officer. There was no suggestion at the

Inquest that her decision to leave the police force was related to the events the subject

of this Inquest.

9.38. Unlike Sergeant Mickan, she was called upon to make a statement about the events of

the night of 25/26 February 2004. Her statement was made on 8 March 2004 and was

admitted as Annexure GM9 to Exhibit C10. She said that she recalled Senior

Constable Redding talking to Christopher Wilson on that night. She said that while

Senior Constable Redding was talking to him at the front counter she was standing

behind listening. She heard one of them say that he had been shot in the leg. She said

he did not appear to be hampered by the wound in any particular way. That further

excited her interest because she had imagined that someone having been shot would

be behaving differently95

.

9.39. Ms Crawford recalled that Senior Constable Redding asked the men what had

happened. She said that members of the group were all talking at once, but she

93



Transcript, pages 588-589

34

overheard Christopher Wilson say that he had been shot in the leg and that the shooter

looked Afghani, dark coloured and he was in a dark vehicle like a BMW. She said

that she definitely heard the word BMW96

. Ms Crawford said that they also reported

that this happened in Duthie Street, Hillcrest97

. According to Ms Crawford, Senior

Constable Redding then decided to take Christopher Wilson to an interview room.

She went out to the back part of the police station and started to do some checks to see

if she could find out any information about the street which had been nominated. She

said that she did this of her own initiative, and not pursuant to a direction from

anyone98

. Ms Crawford said that she entered the name of the street to see if there

were any persons of interest on that street. She said that one of the names which came

up seemed to be a middle eastern or Lebanese type of name. She then typed that

name into the computer and it came up with HB’s details. She was printing out the

different screens as she was moving in and out of them. She noted that there was a

warning next to the name HB to the effect “May be armed” and said that she thought

this may well be the person that was involved99

.

9.40. Ms Crawford said that she would print the pages on the screen straight away before

moving on to another screen100

. She was aware as she was doing these searches that

the Detectives, Green and Wilson, had come down into the station101

. Ms Crawford

printed out four pages from the system between 2347 and 2349 hours on 25 February

2004. Each of the pages bears a time. Annexure GM47 to Exhibit C10 is a copy of

the four pages printed by Ms Crawford during those few minutes. They are copies of

the actual pages printed by her on the night. They could not now be replicated from

the computer system because they bear the date and time referred to above. The

pages are all headed “General Enquiries – Enquire Persons at Address” for Duthie

Street, Hillcrest. The pages reveal the names of seventeen persons recorded in the

computer system for different addresses within Duthie Street, Hillcrest. Most of the

names have been blanked out by the solicitors acting for South Australia Police in this

matter because they are said not be relevant. The names which have not been blanked

out are as follows:

96







35

‘HB DOB 03/03/1984

Warnings: May Be Armed, Psychologic/Psychiatric Disord’

‘HB’S brother DOB 16/09/1980

Warnings: (Blanked out)’

‘B, (Blanked out) DOB (Blanked out)’

‘HB’S brother DOB 16/09/1980’

It was the entry in relation to HB and “May Be Armed” which attracted

Ms Crawford’s interest straight away.

9.41. Ms Crawford immediately decided that this information needed to be conveyed to the

detectives and to Senior Constable Redding.

9.42. Ms Crawford carried out a number of other checks and printed a number of further

documents to which reference will be made in due course. At some point she

collected a bundle of documents from the printer and took them to the interview room

where Senior Constable Redding was taking a statement from Christopher Wilson. At

that time Detectives Wilson and Green were, according to Ms Crawford, standing in

the doorway of the interview room. Ms Crawford went to the doorway where the

detectives were standing and said words to the effect “these are the checks I’ve done,

this is what I’ve found, can you give that to Mick Redding” and she handed the

documents to one of the two detectives102

. Ms Crawford said that she put the

documents together as a bundle. The document on the top was a printout which

included a picture of HB103

. That document appears in evidence as Annexure GM48

to Exhibit C10. It is entitled “Offender Identification – Summary Report” and

provides a description of HB with a number of descriptors of his personal appearance

and repeats the warning details “May Be Armed, Psychologic/Psychiatric Disord

(sic)”. It contains, as I have said, a photograph apparently taken of HB at the City

Watch House on 22 June 2003 at 0430 hours. By reference to Exhibit C18 it can be

ascertained that Annexure GM48 to Exhibit C10 was accessed104

at either 0:25:22 or

0:25:28 hours105

on 26 February 2004.

9.43. According to Ms Crawford once she handed these documents over she returned to her

normal duties. While she was at the front counter she was approached by another

102



It may have been accessed and/or printed at about that time. 105

The distinction is irrelevant.

36

member of the Christopher Wilson group who came to the counter and said words to

the effect “I’ve got a bullet in my car” or “piece of bullet, should I get it”.

Ms Crawford said that she could get it if he showed her where it was. He said that it

was just as easy for him to get it. He ran out and came back with it and during that

time Ms Crawford obtained gloves and a bag to put the bullet or whatever it was. The

item that he produced was described by Ms Crawford as a silver piece of shrapnel106

.

Ms Crawford said that at the time that this was being handed to her Detective Green

was at the counter taking some notes from another person. She said to him that this

had been handed to her and he took possession of it and said that he would deal with

it.

9.44. Ms Crawford said that she did some further computer searches during her shift and

produced a second batch of documents which she handed to Senior Constable

Redding107

.

9.45. Ms Crawford said that of the seventeen names under “Enquire Person at Address” in

Annexure GM47 to Exhibit C10 the name HB was the only one which she thought

had a middle eastern origin108

. She said that the detectives acknowledged the

provision of the material to them by saying “thanks”109

. She said that she

subsequently discussed the matter with Senior Constable Redding and Sergeant

Mickan because she was wondering what would happen about her searches and the

revelation of B as a person of interest. She said that Senior Constable Redding and

Sergeant Mickan responded by telling her that CIB had taken the matter over and

“that was that”110

.

9.46. Ms Crawford said that she gave the detectives information from her computer

searches revealing information about a vehicle. She said “I definitely gave them the

picture of HB and the vehicle information and the address information”111

. She

maintained that the motor vehicle check was in the first lot of information she

provided to the detectives112

. Ms Crawford confirmed her account of the handing of

the material to the detectives with the photograph on top and that there were two

106








37

batches of materials113

. Ms Crawford acknowledged that the motor vehicle check

took place at 00:31:58 hours on 26 February 2004114

.

9.47. Ms Crawford was quite adamant that she handed the information to the detective

while the victim was still in the interview room and she was adamant that this was at a

point after she had done the motor vehicle check not at an earlier stage115

.

9.48. Ms Crawford had made a statement on 8 March 2004 relating the events of the night

of 25/26 February 2004. That statement was admitted as Annexure GM9 to Exhibit

C10. That statement does not refer to Ms Crawford handing the search information to

a detective and then to Senior Constable Redding. She was asked in cross

examination why she had omitted this from the statement. She responded that she did

not mention it in her statement because she handed it to the CIB member to give it, or

with the intention that it be given, to Senior Constable Redding. For that reason she

said she did not incorporate that information into the statement, saying “so I didn’t put

I handed it to them, then they looked at it, then they handed it to him”116

.

9.49. It was put to Ms Crawford by Counsel for Detective Green that at no stage on the

night of 25 February or in the early hours of 26 February 2004 did she hand

information in the form of intelligence checks to a detective from Holden Hill. She

replied:

‘I did. I handed it to them and it's actually in a statement that I provided to IIB.’117

9.50. Detective Mark Wilson

Detective Mark Wilson gave evidence at the Inquest. He was one of the two

detectives present in Holden Hill Police Station when Sergeant Mickan requested the

attendance of CIB that night. Annexure GM5 to Exhibit C10 is a copy of Detective

Wilson’s notes made that night. The note is as follows:

‘Wed 25th Feb 2004

Received info from Sgt Mickan at 2350 hrs. Male walked into front office and been shot

in leg. Possibly slug gun. Spoke with Chris & Mark Wilson states some Afghans in a

BMW pulled a pistol on them. Fired one shot. Small pop noise. Possibly slug gun.

Something hit Chris in the leg and has scratch. No hosp treatment. They were in Duthy

113






38

St Hillcrest. Afghans said stay out of our street. No rego of BMW. Office and patrol

taking statements. Further enq on A shift Thurs with FIO’s.

Off duty 0030 hrs’

The reference to “A shift” is to afternoon shift and the reference to “FIO” is to Field

Intelligence Officer.

9.51. Detective Wilson said that in addition he usually completed a computerised journal at

the completion of each shift. A copy of the journal made by either him or Detective

Green that night was tendered by Counsel for Detective Wilson and admitted as

Exhibit C16. It states:

‘0015 hrs Wilson and Green Report

Received info from Sgt Mickan front office re male has come into front office and thinks

he has been shot by Afghans. Spoke with 4 males who stated they were in Duthy St,

Hillcrest and 2 “Afghans” in a old BMW stopped them and told them not to come into

their street. The pulled a large pistol? Out and a small pop was heard. It was not until

later that one of the boys found he had a graze to the leg. Another occupant of the car

later found what appeared to be a mangled slug in the car. Front office and patrols

taking statements. Offenders not known at this stage and no rego of BMW. Further

enquiries to be conducted in day light. Cont. no hospital treatment sought. Wilson and

Green off duty 0030 hrs.’

Detective Wilson said that it was 2350 hours when the detectives attended and spoke

to Sergeant Mickan in the front office118

. He confirmed that after speaking to

Sergeant Mickan he and Detective Green went to the interview room in which

Christopher Wilson and Dylan Connelly were talking to Senior Constable Redding119

.

Detective Wilson stated that Exhibit C16 and Annexure GM5 to Exhibit C10

contained all the information of which he and Detective Green were appraised that

night120

.

9.52. Detective Wilson, Christopher Wilson and Dylan Connelly discussed what might

have been meant by the exclamation from the occupants of the BMW “not to come

into their street”. Detective Wilson said that Christopher Wilson said that there was

no explanation given by the occupants of the BMW as to why it was “their” street121

.

Detective Wilson said that he and Detective Green returned to their office upstairs at

118





39

Holden Hill Police Station at 0015 hours122

. Before doing so, there was a

conversation between Detective Green, Sergeant Mickan and Detective Wilson.

According to Detective Wilson they reviewed the situation between them and because

there were no suspects and no “rego” to follow up and because the detectives were

already on overtime, and the statements were being taken from the other boys, there

was nothing for the detectives to follow up. It was decided that they would get “the

intel” to do checks on Afghans with black BMWs in the morning and “just to put the

whole file up through the system, yes through the Crime Management Unit”123

.

Detective Wilson said that he and Detective Green discussed the possibility of he and

Detective Green being authorised to stay for overtime to go looking for a black

BMW. He said that they formed the view that they would not have been authorised to

perform that overtime124

because of the fact that they could hunt all night and

probably not find the black BMW.

9.53. Detective Wilson said that from the time that he and Detective Green completed their

computerised journal125

at 0030 hours on 26 February 2004 he had no further

involvement with the matter until after Christopher Wilson’s death. He was not given

any task to be formed in relation to the matter by the Crime Management Unit126

.

9.54. Detective Wilson said that the officer in charge or investigating officer for the matter

on the night was “probably Mick Redding” and elaborated:

‘My understanding is we were going down there to just assess the situation, whether

anything needed to be done straightaway that night and it turned out that it wasn’t so he’s

the senior connie and he was taking the police incident report. … All he’s doing is taking

the report so if you want to call him an investigating officer I suppose he is at that time

but as soon as he gets rid of it to the crime management unit he’s finished.’127

9.55. Detective Wilson gave evidence of going to the front counter while he was down in

the station office and speaking to Mark Wilson. He said that Mark Wilson did not

really want to speak to him. He said that there was another male, apparently part of

the group, who stood back against the wall and did not come up to the counter128

.

122




Exhibit C16 126




40

9.56. Detective Wilson said that he had the feeling that there might have been something

more to the incident which would have meant that it was not random129

. He

elaborated on this later in his evidence saying that he had a feeling that there was

more to it130

. He then added that he did not think that Christopher Wilson himself

was being evasive. He said that it was always hard to obtain details from him and he

was aware of this from a previous assault involving Christopher Wilson as a victim in

which Detective Wilson had been involved. He said it had been difficult to get

information out of him on that occasion and that it was just as if he was not

interested131

. He said that therefore Christopher Wilson was probably behaving

according to his normal disposition but that he considered that the two men out the

front (one of whom was Mark Wilson) were not cooperating132

.

9.57. Detective Wilson said that he was under the understanding that all statements from

the group would be taken that night by members of the office and patrols133

.

9.58. Detective Wilson said that he had no recollection that a woman police officer was on

duty that night134

. At that time he did not know Tina Crawford135

. He was shown

Annexure GM47 to Exhibit C10, which is the four pages entitled “General Enquiries

– Enquire Persons at Address” referred to previously, and asked whether he saw those

documents being handed over by Ms Crawford on that night either directly to him or

to someone else or in his presence136

. He added that he had never seen the documents

set out in Annexure GM47 to Exhibit C10 at any time prior to giving evidence in the

Coroner’s Court137

. He had no knowledge of a check on HB138

.

9.59. Detective Wilson confirmed that he and Detective Green were aware that somebody

had been shot before they went down to the front office that night139

.

9.60. Detective Wilson denied that Sergeant Mickan had told him that computer checks had

been generated that night. He said that they did not discuss computer checks that

129












41

night140

. He acknowledged that the decision to leave the matter to the following day

for allocation by the Crime Management Unit was his call141

.

9.61. Detective Wilson said that when he spoke to Mark Wilson, Mark Wilson did not say

that he knew who the assailant was. In fact he said that he did not know who the

assailant was and did not know the car142

. Detective Wilson denied that he and

Detective Green had taken over the job that night143

.

9.62. Detective Stuart Green

Detective Green gave an account of the events of 25/26 February 2004 that accorded,

in the broad, with that of Detective Mark Wilson. Annexure GM6 to Exhibit C10 is a

copy of a handwritten note made by Detective Green on that night. It records that at

2345 hours Detective Green was contacted by Sergeant Mickan about a male person

presenting at the police station alleging he had been shot by a group of Afghans,

possibly by a slug. It records that Detective Green went off duty at 0030 hours. The

note refers to the names of Ryan Williams, James McAinsh and Mark Wilson and

gives ages and contact details. Curiously, the note does not refer to the name of

Christopher Wilson. Detective Green confirmed the accuracy of this note and of the

computerised journal144

which was referred to previously.

9.63. Detective Green said he would have noted the time of 2345 hours before going down

stairs to the station proper. He was aware before going down that a person had

presented at the station alleging that he had been shot in the leg145

. Detective Green

said that he and Detective Wilson went downstairs to the station proper and straight

into the interview room with Senior Constable Redding and Christopher Wilson146

.

Detective Green recalled that Christopher Wilson had said words to the effect that he

thought he had been shot with some sort of gun but did not think it was real147

.

Detective Green saw the wound on Christopher Wilson’s leg and described it in

evidence as “just a small scratch”148

. According to Detective Green, Christopher

Wilson was not overly concerned about “the cut on his leg” and was not going to seek

140





Exhibit C16 145





42

medical attention because he did not think he had been shot with a real gun but

possibly a slug gun149

.

9.64. Detective Green said that he spoke to Mark Wilson and some of the other men at the

front counter. None of them volunteered a name of an assailant. At this point

Detective Green said that he was approached by Probationary Constable Tina

Crawford who handed him a plastic bag with some sort of metal projectile in it. He

had not spoken to her prior to this150

. He said that Probationary Constable Crawford

informed him that somebody had retrieved this from the vehicle and given it to her.

Detective Green took this plastic bag to Detective Wilson. He said that they

discussed the object and decided that it was more than likely a slug. He said that there

was a conversation with Senior Constable Redding and Christopher Wilson “and it

was agreed by all parties that they were all of the opinion that it was a slug”151

.

9.65. Detective Green said that he and Detective Wilson then had a further conversation

between themselves outside the interview room. This conversation was to the effect

that “the matter was I believed of a less serious nature because of the fact that the

weapon used was more than likely a slug gun”. Because there were no lines of

inquiry to follow up (that is no address, no suspect’s name and no registration number

for a vehicle), and no other information was “provided to us” at that time, they would

approach Sergeant Mickan and “put our side of the story to him”152

. He then

described the subsequent conversation between himself, Detective Wilson and

Sergeant Mickan. They informed Sergeant Mickan that they did not think it likely

that they would achieve anything by conducting further inquiries themselves on the

night and that the matter would be “better suited for day shift to follow it up as we

were off duty”153

. Detective Green said that it would have been possible for he and

Detective Wilson to be “recalled” to duty but that based on the information that they

“were given” they thought it highly unlikely that they would be given authorisation to

be recalled154

.

9.66. Detective Green said that Senior Constable Redding expressed concerns to him about

Christopher Wilson’s version of events. Senior Constable Redding thought that what

149







43

Christopher Wilson was saying “didn’t seem quite right and wasn’t adding up”155

.

Furthermore, Detective Green said that his first thought was that it was “a little bit

odd” that Christopher Wilson and his friends had come to the police station and not

sought medical treatment if there had been a shooting156

and that this did not add

up157

. He said that they thought that the firearm may not have been a revolver or a

long barrel rifle and that was “the reason why we treated it as a less serious thing”158

.

He said that he felt that Christopher Wilson was not telling them everything159

.

Finally, he said that looking at the projectile he was not convinced that it was a bullet

and thought that it was a slug160

.

9.67. Detective Green said that he and Detective Wilson returned upstairs to their office,

made a journal entry on the computerised journal at about 0015 hours and then left the

building. He said that he estimated that he left the building just before 12:30am161

.

Detective Green was shown Annexure GM47 to Exhibit C10, the four page printout

of persons at Duthie Street previously referred to and generated by Probationary

Constable Crawford at approximately 11:47pm on 25 February 2004. He said that he

did not see any of those four pages prior to completing his shift that night and was not

present when it was handed to any other member of police. He said that the first time

he saw the document was when it was shown to him by his lawyer shortly before the

Inquest162

.

9.68. Detective Green denied that he had heard the expression “road rage” mentioned by

any police officer or civilian that night163

.

9.69. Detective Green said that his understanding of his role and that of Detective Wilson

that night was simply to assess the situation and proffer advice as to how the matter

should progress, but not to take it over164

and that he understood that the further

155








Transcript, pages 524, 556 and 570 163



44

conduct of the matter for that night was with Sergeant Mickan and Senior Constable

Redding165

.

9.70. Detective Green said that he would have expected that any computer checks which

had been generated in the course of the evening would have been shown to him166

.

He agreed that the information concerning a dark coloured BMW, a firearm and the

street name of Duthie Street would be sufficient for computer checks to be

conducted167

.

9.71. Detective Green said that he and Detective Wilson were approached by Acting

Detective Sergeant Addison at the commencement of their afternoon shift the

following day, namely 26 February 2004. Acting Detective Sergeant Addison was

aware that they had had some involvement with the Christopher Wilson incident the

previous night. He inquired of them what the job was about. Detective Green said

that he and Detective Wilson provided Acting Detective Sergeant Addison with an

overview of what had happened the previous evening. This occurred at

approximately 3:00pm on 26 February 2004.

9.72. Detective Green was asked by his own Counsel to assume that he had had knowledge

that night that a revolver had been used in relation to the shooting. He provided a

very detailed answer the effect of which was that there would have been “a different

set of procedures put in place”. He said the matter would have been treated as a “high

risk listing”, there would have been advice to the shift manager, to the on-call officer,

to police communications, to the on-call STAR Group officer, a briefing conducted,

uniform patrols attending, placement of cordons and a tactical commander assuming

responsibility for the incident168

. However, he said that he was not aware that

witnesses spoken to that night had described the weapon used as a pistol until some

time after that night169

.

9.73. Senior Constable Peter Cox and Senior Constable Luke Wilson

These police officers were the two patrol officers who were called back to Holden

Hill Police Station at the request of Sergeant Mickan by Sergeant Tuk, the officer in

charge of patrols. The joint daily activity log of Senior Constable Luke Wilson and

165






45

Senior Constable Peter Cox170

confirms that from 0005 to 0125 hours they were at

Holden Hill Police Station to assisting in the taking of the statements. Senior

Constable Cox said that he attended at the front foyer area of Holden Hill Police

Station and spoke to Detective Green who asked them to take a statement from the

driver of the vehicle who turned out to be James McAinsh. He confirmed that he

proceeded to do just that. He said that once he had finished taking the statement he

handed it to Senior Constable Redding171

. He said that as soon as the statements were

handed in they resumed patrol duties172

. It was clear that very little time expired

between the completion of the statements and the resumption of patrol duties173

.

Senior Constable Cox could tell that Senior Constable Redding had completed taking

whatever statement he had taken (we now know it was the statement of Christopher

Wilson) prior to Senior Constable Cox completing his. Neither Senior Constable Cox

nor Senior Constable Luke Wilson was aware of Senior Constable Redding’s

presence on their arrival at the police station. All of the evidence suggests that Senior

Constable Redding was in the interview room with Christopher Wilson at that point.

Senior Constable Cox said that James McAinsh was cooperative and did not appear to

be holding anything back174

.

9.74. Senior Constable Luke Wilson gave evidence to a similar effect as that given by

Senior Constable Cox. He confirmed that he took a statement from Dylan Connelly

and that he commenced taking that statement at 0005 hours and finished doing so

shortly before 0125 hours. He said that he handed his completed statement to Senior

Constable Redding175

. He said that he did not have any difficulty in obtaining

information from Dylan Connelly who was quite forthcoming with details176

.

9.75. The evidence of both of these officers confirms that Senior Constable Redding was

free from the task of taking a statement from Christopher Wilson prior to the

completion of the statements that Senior Constable Cox and Senior Constable Wilson

were tasked to take. There was no reason why Senior Constable Redding could not

have used this time, it seems to me, to be taking a statement from either of Mark

Wilson or Ryan Williams.

170

Exhibit C15 171







46

10. The Christopher Wilson complaint - Conclusions

10.1. Senior Constable Redding somehow did not pick up the information that Probationary

Constable Tina Crawford picked up, namely that Christopher Wilson had been shot

and wounded. Senior Constable Redding’s evidence in chief was built upon the

premise that this was information that was only reluctantly revealed by Christopher

Wilson at a very late stage in the interaction between him and Senior Constable

Redding. The premise was that there was a gradual change in the story from a “road

rage” incident, to an assault involving a bat or other like object, to a shooting and

finally to a shooting and a wounding, and this last only at a very late stage. However,

while Senior Constable Redding was sitting with Christopher Wilson in the interview

room eliciting what he descried as a changing story, Probationary Constable Crawford

was already pursuing fruitful lines of inquiry based upon her appreciation, gained

almost immediately upon the arrival of Christopher Wilson at the Holden Hill Police

Station, that he had been shot and wounded by “Afghans”. It is extremely difficult to

imagine how Senior Constable Redding managed to remain oblivious to this for so

long. Was he distracted when that was mentioned at the front counter? Was his

hearing impaired by something? Was he being truthful or did he hear the same things

as Probationary Constable Crawford but was reluctant to accept that it was true until

Christopher Wilson, having been forced to go through the story at length in the

interview room finally got the point of the narrative where he was shot and revealed

the wound. Did this in turn enable Senior Constable Redding to suggest that the

wound was a late revelation reluctantly made thus establishing Senior Constable

Redding with a foundation for his belief that something “did not add up”, that

Christopher Wilson was “holding something back”. It will be remembered that

Senior Constable Redding added a touch of mystery to his account by reference to the

“shadowy figure” that met Christopher Wilson outside the station after he had been

shown into an empty foyer by Senior Constable Redding after the completion of the

interview.

10.2. In any event, I find that Christopher Wilson did indeed mention the wound and the

shooting at a very early point at the front counter thus enabling Probationary

Constable Crawford to hear it and begin her inquiries. I am unable to explain why

Senior Constable Redding would have been unable to hear something that could be

heard by Probationary Constable Crawford.

47

10.3. Senior Constable Redding passed his suspicions about Christopher Wilson’s

unwillingness to cooperate onto other police officers that night, namely Sergeant

Mickan, Detective Green and Detective Wilson. However, neither Senior Constable

Cox nor Constable Luke Wilson noted a lack of cooperation on the behalf of James

McAinsh or Dylan Connelly.

10.4. All the members of the Christopher Wilson party gave evidence that they did not feel

that the complaint had been taken seriously by the police that night. This may be

explained by the fact that Senior Constable Redding apparently did not take in the

information about the wounding by gunshot until well into the interview with

Christopher Wilson when none of the others with the exception of Dylan Connelly

was present. The others would be left wondering why there was not some more

urgent response to a report of a shooting, if it was accepted at face value.

10.5. They were not to know that it had been accepted at face value by Probationary

Constable Crawford. By face value, I am referring to the initial attendance in the

foyer by the Christopher Wilson party on their arrival at the Holden Hill Police

Station, and the acceptance of the account of a shooting and wounding at that point.

From the point of view of the rest of the members of the Christopher Wilson group,

the public face of South Australia Police was Senior Constable Redding, who

somehow missed the central message that was being conveyed, namely that

Christopher Wilson had been shot and wounded by “Afghans”. It is quite possible

that the members of the group felt that they were not being taken seriously if Senior

Constable Redding, the only officer to whom they initially spoke, did not realise that

they were saying that Christopher Wilson had been shot and wounded.

10.6. Detectives Wilson and Green were both adamant that none of the results of the

searches by Probationary Constable Crawford had been shown to them that night.

Probationary Constable Crawford was just as adamant that she had handed the search

results to one of the detectives in the presence of the other, for handing to Senior

Constable Redding. Both detectives denied that this occurred.

10.7. Sergeant Mickan was quite sure that he gave the detectives information about the

searches, including the name HB.

10.8. The initial search results “Enquire persons at address” for Duthie Street revealed the

name HB together with the warnings “May be armed” and “Psych disorder”. That

48

information was in existence at 11:47pm and had been printed. On Probationary

Constable Tina Crawford’s evidence she left a pile of material on the printer before

taking it to the interview room and handing it to the detectives. She was adamant that

the final check she did before this was the vehicle details check which was not done

and printed until 0032 hours on 26 February 2004. By that time the detectives had

returned to their office upstairs, completed their journal entries and left the building

(at 0030 hours).

10.9. If I were to accept that Probationary Constable Crawford did not hand over anything

until after she printed the vehicle enquiry details, then it would not have been possible

for the detectives to have been present when the material was handed over as

recounted by Probationary Constable Crawford. This would mean that her evidence

would have to be rejected on this point – that notwithstanding her emphatic assertions

that she handed the checks to the detectives for transmission to Senior Constable

Redding, she did not. It would be difficult to conclude that Probationary Constable

Crawford was mistaken in that evidence given her repeated vehement assertions that

this did happen.

10.10. On the other hand, if I accept that Sergeant Mickan was correct in saying that he told

the detectives about the searches before they left the office that night, and assume

Probationary Constable Crawford was mistaken in recalling that the vehicle enquiry

searches were included in the package of information she handed to the detectives or

Senior Constable Redding, then it may be possible to conclude that some

computerised search information, including the details about HB, was provided to the

detectives before they left that night. However, this conclusion would necessarily

entail finding that the detectives were both lying. It would be difficult to find they

were mistaken because they were as adamant in their evidence that they were not

shown any searches nor provided with any verbal report of searches as Probationary

Constable Crawford and Sergeant Mickan were in their assertions to the contrary.

10.11. I am in a position where, if I am to resolve the issue of the knowledge of the

detectives about the search results in the early morning of 26 February 2004, I must

find that either:

1. Detectives Wilson and Green are lying and Sergeant Mickan and Probationary

Constable Crawford are telling the truth.

49

2. Sergeant Mickan and Probationary Constable Crawford are lying and Detectives

Wilson and Green are telling the truth.

I have acknowledged that the version of events given by the detectives is supported by

the times shown on the computer record of the vehicle checks. However, this is only

to the extent that Probationary Constable Crawford is not mistaken in her belief that

the vehicle checks were part of the package of checks she maintains she gave to the

detectives. In the result, I am unable to reach a conclusion on the matter. I have

reached the conclusion though that the discrepancy is not explicable by a genuine

mistake on the part of one side or the other. Either Detectives Wilson and Green on

the one hand or Probationary Constable Crawford and Sergeant Mickan on the other,

have been untruthful at the Inquest.

10.12. With the exception of Probationary Constable Crawford, and Senior Constable Cox

and Constable Luke Wilson, all officers involved on the night of 25/26 February 2004

said that things did not add up, that something was being held back and that there was

a suspicion that the event was not random as alleged by the Christopher Wilson party.

10.13. The wound was variously described as a scratch, looking like a cigarette burn, a small

crater. Christopher Wilson was described as nonchalant and not looking for medical

treatment. The gun was only a slug gun or an air gun and only made a popping noise.

10.14. There was a general tendency to minimise the seriousness of the presentation that

night. None of the officers when asked directly suggested that a minor wounding,

even with an air gun, was not a serious matter. Yet somehow it was relevant that the

wound was minor, that the gun made a popping noise, and that the projectile appeared

to be a slug.

10.15. Detectives Wilson and Green and Senior Constable Redding said that the projectile

appeared to be a slug. They said that Christopher Wilson and Dylan Connelly agreed.

None of them had ballistics training. None of them appeared to consider that it was

obvious from the story given by Christopher Wilson that the projectile was not fired

directly at him but that it had ricocheted off something else and spent most of its force

before hitting him. None of them appeared to consider that this meant that the

weapon was less likely to be an air gun and the projectile not a slug177

. When it was

177

The exception is Dylan Connelly, who said that he made this point to the detectives. Transcript, page 1411

50

suggested to Senior Constable Redding that the projectile had hit the road before

hitting Christopher Wilson and this may not be considered to be consistent with a low

powered air gun, it was explained that some higher calibre air guns are actually quite

powerful178

.

10.16. There was a tendency by Detective Green, Detective Wilson, Senior Constable

Redding and Sergeant Mickan to suggest that it was accepted as a serious incident,

but to point out that observations made by them decried the seriousness of the

incident. This was something of the best of both worlds: an acknowledgement of the

seriousness of the shooting (which, in hindsight, could hardly be denied, now that we

know that there was no air gun but a Ruger revolver)179

but an emphasis on the factors

which would justify the treatment of the matter as less serious. Detective Green did

admit that they treated the matter as less serious180

.

10.17. It was unacceptable to blame, as some witnesses did, Christopher Wilson for the lack

of urgency and action. Senior Constable Redding went so far as to suggest that the

incident was trivialised by Christopher Wilson181

. Even if the victim of a shooting

incident that police have no reason to believe is anything other than random (and all

the evidence in this case suggests that the incident was indeed random) has some

oddity of character that causes him not to be reacting in the way that one would

normally expect, that should not lead to an assumption that the matter is not as serious

as it might be. Public safety requires that an open mind be maintained. It is all very

well to make assumptions based on vague feelings and suspicions and other highly

subjective factors that a matter is not as serious as at first appears. The fact in this

case was that there was a person at large who had used a gun in a public place for no

better reason than that some people had driven into “his street” and that as a result, a

member of the public who had done nothing to provoke this had been injured –

fortunately, not seriously. There was no reason to believe that the incident would not

be repeated other than feelings said to be based on experience, but more likely born or

apathy, that the incident was not random and something was being held back.

10.18. Yet the incident had been reported by a group of people who had been prepared to

come into a police station shortly before midnight to make a formal complaint. Three

178


Annexure GM37 to Exhibit C10 180



51

of their number were interviewed and gave statements. In all they spent as a group at

least two hours in the vicinity of Holden Hill Police Station waiting around. That can

hardly be described as uncooperative.

10.19. The evidence given at Inquest by some members of the Wilson group was, I suspect,

somewhat exaggerated. For example, reference by James McAinsh to a smirk182

, by

Dylan Connelly to officers chuckling at the wound183

, are more likely to reflect some

degree of animus on their part towards the police than a true account. Having said

that, I do believe that these witnesses generally provided a true account and tried to

recall as faithfully as possible the events in question.

10.20. There should have been a far more rigorous response by the officers in Holden Hill

Police Station involved in the investigation of the matter that night (with the

exception of Probationary Constable Tina Crawford, whose involvement was

probably purely of her own initiative and born of enthusiasm) and officers Luke

Wilson and Peter Cox who were given a specific task to do in the matter which they

did before resuming their patrol duties. It is notable that neither Constable Luke

Wilson nor Senior Constable Peter Cox reported any lack of cooperation or any vague

notions of a tendency on the part of their interviewees to hold things back. They had

no incentive to offer any justification for their actions that night. They showed no

lack of rigour in their approach.

11. Police response – community expectation

11.1. What should the community expect of its police force in a situation such as this? Let

us assume that there was some bravado by Christopher Wilson that the wound was

only minor and did not hurt or require medical treatment and agreement by

Christopher Wilson that the projectile was in all probability a slug. But that does not

change the fact that a member of the public had presented in the police station to

report that he had been wounded, albeit not seriously, by a projectile discharged from

a firearm of some sort with sufficient power to cause the wound after having spent its

initial force in ricocheting off something else, most likely the road surface, and that

the incident was not provoked in any way but that the shooter was yelling out that the

victim should keep out of “his street” and demanding to know what the victim was

182



52

doing in “his street”. The victim was accompanied by four eye witnesses. None of

them was heard to say that he knew the shooter. However, they did say that the

incident occurred after they had made a wrong turn down a street from which the

shooter apparently pursued them shortly afterwards, flagging them down in a nearby

street.

11.2. I believe that the community had a right to expect that such an incident would be

responded to as an immediate priority until the police have some basis to explain the

conduct as being other than random. Until there is such a basis the community is

theoretically at general risk. There may be other incidents involving this person. He

may decide to accost someone else who drives into and out of his street. Bearing in

mind that it is a public street, there is a likelihood that this might occur. The

apparently irrational shooter might repeat his violent behaviour.

11.3. All this might seem unlikely. It might seem improbable that someone would be

sufficiently deranged to take such exception to a car full of persons driving in his

street as to flag them down and shoot one of their number if only inadvertently by

ricochet. In the event that such a thing does occur, it is the police to whom the public

turn for a response. It is the police who are charged with upholding law and order. It

is not acceptable for the police to react to this by regarding it as inherently unlikely,

probably explicable by some connection between the complainant and the shooter

which the complainant is for reasons of his own concealing, and to proceed on the

assumption that the shooter will not repeat his behaviour. Instead, the police should

assume that there is a person who is willing to discharge a firearm in the vicinity of

the location in question, who regards some public street as “his street” and who may

therefore be a resident of that street. Police should then take steps to secure the peace

and restore public safety.

12. The further handling of the complaint made by Christopher Wilson after he left

the Holden Hill Police Station

12.1. On 26 February 2004 at 1:17am Senior Constable Redding updated the PIR

investigation diary summarising the status of the investigation184

. He noted that

Christopher Wilson had been advised to attend Holden Hill Police Station in the

184

Annexure GM1 to Exhibit C10

53

morning to have his wound photographed by technical services. Senior Constable

Redding also noted that HB was a person of interest and may be a possible suspect.

12.2. Senior Constable Redding also submitted a hard copy of that same PIR, along with a

copy of Christopher Wilson’s statement and copies of the searches that Probationary

Constable Crawford had done to Sergeant Mickan for vetting. Sergeant Mickan

forwarded the electronic PIR as well as the hard copy PIR and the statement and

searches to the Crime Management Unit or CMU for allocation at approximately

4:57am on 26 February 2004185

.

12.3. At approximately 7:00am on 26 February 2004, Senior Constable McGowan checked

the Holden Hill Scene overnight book, and discovered that there was an overnight

tasking for Christopher Wilson’s injury to be photographed186

. Senior Constable

McGowan attempted to contact Christopher Wilson by telephone at approximately

10:00am, 11:45am and 12:30pm187

. At 3:00pm Senior Constable McGowan asked

Senior Constable Marzano to make further enquiries and contact Christopher

Wilson188

. Senior Constable Marzano contacted Senior Constable Roger Delaat of

Adelaide Crime Scene Investigation Unit to take the tasking189

. Senior Constable

Delaat attended Christopher Wilson’s home at approximately 5:50pm. The door was

not answered and he left a calling card in it190

. At 9:43pm it was noted in the PIR

investigation diary that Christopher Wilson had not attended Holden Hill Police

Station to have his wound photographed191

.

12.4. At Holden Hill Police Station there is an Intelligence Section. One of the duties of

that section is to prepare a daily briefing sheet which gathers details of events from

the previous twenty-four hours which may be of interest to the Local Service Area.

The briefing sheet is prepared by one or more Field Intelligence Officers. These

officers obtain intelligence material from different sources in order to create the

briefing sheet. Annexure GM58 to Exhibit C10 is a copy of the Holden Hill Crime

Management Journal for 26 February 2004. It contains an entry relating Christopher

Wilson’s complaint. It contains a reference to the number of the PIR. It seems likely

185





Annexure GM34 to Exhibit C10, Exhibit C7a 190

Annexure GM34 to Exhibit C10, Exhibit C7a, Exhibit C12e and evidence of Mrs Julie Wilson 191


54

that the entry in the Crime Management Journal was made by Senior Constable

Redding. It is most probably that journal together with the PIR that triggered an entry

in the Holden Hill LSA Intelligence Section daily briefing in relation to the

Christopher Wilson incident. This is evidenced by an extract from the Holden Hill

LSA Intelligence Section daily briefing for 26 February 2004 a copy of which appears

as Annexure GM59 to Exhibit C10. The daily intelligence briefings that are prepared

by the intelligence officers are presented to the daily Tactical Coordination Group

(“TCG”) meeting for discussion and action. Annexure GM59 to Exhibit C10

indicates that the intelligence briefing was indeed distributed at a TCG meeting that

day. Detective Senior Sergeant Eric Douglas was the Acting Detective Chief

Inspector on the evening of 25 February 2004. He was not on duty at the time

Christopher Wilson and his friends attended at the police station. He first became

aware of the incident at the TCG meeting on the morning of 26 February 2004.

12.5. At the time Detective Senior Sergeant Douglas considered the matter he recognised

the incident as serious. However it appeared to him that there was not, by that stage,

an imminent or immediate danger to the public arising out of the incident192

. He

decided that the matter should be actioned by the CIB officers who had been on duty

when the report occurred, namely Detectives Wilson and Green. He did not allocate

the matter to the day shift CIB members because they were routinely off duty on

Saturdays and Sundays and thus there would have been a risk of interruption and

delay in the investigation193

. Detective Senior Sergeant Douglas prepared a

forwarding minute194

stating “for allocation to 2 Team for investigation please”. The

forwarding minute was attached to the PIR and forwarded to the Crime Management

Unit for that instruction to be actioned. The reference to “2 Team” was a reference to

Team 2 of Investigations Division of which Detectives Wilson and Green were a

part195

.

12.6. The forwarding minute with the PIR was physically received by Sergeant Kelly, a

member of the Crime Management Unit. Receipt of the hard copy was acknowledged

by Sergeant Kelly’s signature on the minute196

. Sergeant Kelly then allocated the PIR

to Detective Sergeant Butvila who Sergeant Kelly mistakenly believed was the person

192



Exhibit C26 195


Exhibit C26

55

then in charge of Team 2 because Detective Sergeant Butvila was usually in that

position. However, at that time, Detective Sergeant Butvila was relieving in the

position of Acting Detective Senior Sergeant of Investigation and Response, which

was primarily an administrative role and did not involve any direct and immediate

supervision of Team 2. Instead he oversaw all of the Investigations Section as well as

the Crime Management Unit197

. Sergeant Kelly had access to the weekly dispositions

journal198

which showed that Detective Sergeant Butvila was relieving up and

similarly that Acting Detective Sergeant Addison was also relieving up and therefore

in charge of Team 2. Sergeant Kelly gave evidence that he acknowledged that the

PIR was to be allocated to Team 2 and not to Detective Sergeant Butvila directly. He

explained that he sent the file to Detective Sergeant Butvila because he knew he was

generally the sergeant in charge of Team 2. He acknowledged that he did not check

the dispositions journal but allocated the PIR to Detective Sergeant Butvila because

he was associated with Team 2.

12.7. As I have said Acting Detective Sergeant Shane Addison was in charge of Team 2 at

the relevant time and was the direct supervisor of the members of that team199

. The

PIR was sent electronically using the police information management system.

Furthermore, a hard copy of the PIR followed thereafter. Thus both the electronic

version and the hard copy version were forwarded to Detective Sergeant Butvila.

12.8. When a PIR is electronically allocated it goes into the system and when the relevant

members logs onto the system he or she receives notification of matters that have

arrived and are awaiting their attention. If a member does not log onto the Police

Information Management System, then he or she will not receive any electronic

notification of the arrival of a new matter. The member will not have notice of the

new matter until that member logs onto the system200

.

12.9. Both Detective Sergeants Butvila and Addison had their own pigeon holes into which

hard copy material would be placed by a rounds clerk who did rounds at least twice a

197

Evidence of Detective Sergeant Butvila; Exhibit C26d 198

Exhibit C26d 199

Exhibit C26d 200

Evidence of Detective Senior Sergeant Douglas; Detective Sergeant Butvila; Detective Sergeant Addison and

Sergeant Kelly

56

day, in the morning and in the afternoon. Those pigeon holes were located near the

Detective Sergeant of Investigation’s office201

.

12.10. Detective Sergeant Butvila’s usual office was being temporarily occupied by Acting

Detective Sergeant Addison while they were both relieving. There were two trays

located on the desk in that office, one of which was allocated for general purpose

materials relevant to Team 2 investigations, and the other one was for personal

correspondence addressed to Detective Sergeant Butvila202

.

12.11. While relieving up, Detective Sergeant Butvila did not regularly access the PIMS as

his role as an Acting Detective Senior Sergeant did not require him to do so and

because he was not required to receive and allocate matters for investigation while

relieving up. On occasion, he would log onto PIMS and would forward on to the

relevant person, usually Acting Detective Sergeant Addison, any material that might

have been incorrectly forwarded to him. However, there was no regularity to his

logging onto PIMS203

.

12.12. While relieving up, Detective Sergeant Butvila would not necessarily check his

pigeon hole with regularity either and for the same reason204

. While relieving up,

Detective Sergeant Addison was in charge of the receipt and allocation of matters for

investigation by members of Team 2 and he relied upon those matters being

forwarded to him. He relied upon the hard copy of those matters being placed in his

pigeon hole. Detective Sergeant Butvila assumed that Detective Sergeant Addison

would check Detective Sergeant Butvila’s pigeon hole and remove anything that

related to Team 2. However, Detective Sergeant Addison believed that it was not his

place to check Detective Sergeant Butvila’s pigeon hole and assumed that Detective

Sergeant Butvila would check it himself.

12.13. The staffing arrangements for the Holden Hill CIB were recorded in a document

called the Holden Hill CIB Disposition sheet205

. That document was collated, updated

and distributed on a weekly basis to staff members206

. Members of the Crime

Management Unit were aware of and had ready access to the Holden Hill CIB

201

Evidence of Detective Senior Sergeant Douglas and Detective Sergeant Butvila 202

Evidence of Detective Sergeant Butvila and Detective Sergeant Addison 203


Evidence of Detective Sergeant Butvila and Detective Sergeant Addison. 205

Exhibit C26d 206

Evidence of Detective Sergeant Butvila, Detective Senior Sergeant Douglas and Sergeant Kelly

57

Disposition sheet every week and were aware that it could be accessed on their

computers207

. Annexure GM1 to Exhibit C10 contains an entry at 1433 hours on

26 February 2004. It was made by Sergeant Kelly and it refers to the Christopher

Wilson PIR. It states:

‘Vic for alloc as per direction of DS/Sgt Douglas. Hard copy to you 26/2’

And it records the transfer to Detective Sergeant Butvila.

12.14. In the result, neither Detective Sergeant Butvila nor Detective Sergeant Addison

received the electronic version of the Christopher Wilson PIR on 26 February 2004 as

intended. Nor did either of them receive the hard copy documents208

. In fact

Detective Sergeant Butvila had no knowledge of the matter at all until Internal

Investigation Branch began investigating the matter more than twelve months later209

.

12.15. As already noted previously, Detective Sergeant Addison who was working on

afternoon shift along with Detectives Wilson and Green became aware of their

involvement in the Christopher Wilson incident at approximately 3:00pm on

26 February 2004210

. However at the time of this discussion he was not in possession

of the PIR in any form and did not come into possession of it until he sought out an

electronic copy of it himself on 28 February 2004 at the request of Detective Lidio

Santucci who had asked for it to be forwarded to him in relation to the fatal shooting

of Christopher Wilson. The hard copy documents arrived on the desk Detective

Sergeant Addison was occupying some time during the afternoon of 28 February

2004. He passed this on to Detective Santucci and made a note on the forwarding

minute as follows:

‘Lidio, this is for you too. Makes very interesting reading now.’

12.16. Other than the efforts made by the crime scene examiners in connection with

photographing Christopher Wilson’s wound, and apart from the allocation of the PIR

(or misallocation), no other action took place in relation to the complaint by

Christopher Wilson until after his death on 28 February, 2004. The misallocation of

the PIR reflects poorly on Sergeant Kelly. His evidence at T1702-1706 shows that he

had a rather casual attitude in relation to ascertaining the identity of the person acting

207

Evidence of Detective Sergeant Butvila and Sergeant Kelly 208


Evidence of Detective Sergeant Butvila 210

In discussion with them, but not as a result of the allocation of the PIR.

58

in a particular position at a particular time. This is evidenced by his comments that

“you’ve got to appreciate there was always changes and relieving and it was an

ongoing matter”211

and “you just throw it around there. I’d say whose relieving in

that position at the moment or is so and so relieving. I mean its just general talk

within the confines of the staff there at the Crime Management Unit.”212

As to the

disposition journal he said:

‘Every now and again you get on to it. Depending what you were working on and what

you were looking at, but, I mean, you know, we have a hundreds tasks to do there. It

was just one of many.’213

In my opinion Sergeant Kelly was less than diligent in his approach to the allocation

of the Christopher Wilson PIR. If his evidence is any indication of his attitude to the

importance of accurate allocation generally, it appears that he does not attach

sufficient importance to the accurate transmission of PIRs. As this case has shown, a

high level of diligence is required in this task.

12.17. In the result, neither Detective Sergeant Butvila nor Detective Sergeant Addison

received the electronic version of the Christopher Wilson PIR on 26 February 2004 as

intended. Nor did either of them receive the hard copy documents214

. In fact

Detective Sergeant Butvila had no knowledge of the matter at all until Internal

Investigation Branch began investigating the matter more than twelve months later215

.

13. Human source information

13.1. According to an affidavit of former Detective Brevet Sergeant Edgecombe, he was

attached to the Informant Management Liaison Office at the Holden Hill CIB. He

was responsible for the management of human sources and the safe dissemination of

information they provided. At an Informant Management Liaison Office meeting

with members of the Informant Management Section (now referred to as the Human

Source Management Section) between July and October 2003 he was advised of

information received from a registered informant. The information was that HB, who

resided within the Holden Hill Local Service Area was in possession of a revolver.

An information report describing this information was tabled at the meeting. This

211





Evidence of Detective Sergeant Butvila

59

information report is the same information as referred to in the affidavit of Detective

Senior Sergeant Grant Garritty216

. According to an affidavit of Detective Brevet

Sergeant Edgecombe which was admitted as Exhibit C38 in these proceedings, after

the meeting of the Human Source Management Section referred to above he had a

conversation with then Detective Senior Sergeant Saunders who was in charge of the

Holden Hill CIB Tactical Unit at that time. Detective Senior Sergeant Garritty

advised Detective Senior Sergeant Saunders of the nature of the information and

sought his assistance in allocating the information report to his staff for follow up.

Detective Senior Sergeant Saunders informed him that staffing problems prohibited

him from providing any tactical resources. On the advice of Detective Senior

Sergeant Saunders he then spoke with the Holden Hill Operation Mantle staff who

were thought to be able to assist. Detective Senior Sergeant Garritty then briefed

members of Operation Mantle and understood that the informant information would

be followed up by members of that team.

13.2. Between July and October 2003, Detective Senior Sergeant Garritty spoke with

members of Operation Mantle on a regular basis in the ordinary course of his duties.

On one of those occasions he inquired about the status of the informant information

and was told that the Operation Mantle members had been unable to act on the

information but had passed it on to members of Operation Nail, a Holden Hill uniform

tactical team involved in the investigation of local youth gang activity. Detective

Senior Sergeant Garritty then spoke with Constable Lawton of Operation Nail and

was advised by him that apart from driving past HB’s address on a number of

occasions, Operation Nail members had not been able to further any investigation due

to lack of staffing. Detective Senior Sergeant Garritty again met with Detective

Senior Sergeant Saunders and again asked for the allocation of staff from CIB

Tactical Unit to deal with the informant information about HB possessing a firearm.

During this conversation, according to Detective Senior Sergeant Garritty, Detective

Senior Sergeant Saunders said that the tactical team would investigate the matter but

that it would be delayed for a week because of a lack of staff.

13.3. As I noted in paragraph 6.4 of this Finding, HB had appeared before the Youth Court

on 8 July 2003. He had entered into an obligation with the Court to be of good

behaviour for a period of eighteen months. Condition 5 of the obligation prohibited

216

Exhibit C40

60

him from possessing or carrying any firearm or offensive weapon. This information

was available to members of South Australia Police217

.

14. The Dreelan PIR

14.1. Annexure GM63 to Exhibit C10 is a copy of a Police Incident Report submitted by

Constable Denise Case of Holden Hill Police Station at 12:46pm on 20 October 2003.

Annexure GM64 to Exhibit C10 is a statement which was given by the complainant,

Clive Patrick Dreelan, to Constable Lawrence at 1:30pm that day. The essence of the

complaint was that Mr Dreelan’s life had been threatened by a person he knew only as

“HB”. He would recognise HB if he saw him again because he had known him for

approximately six to eight months according to this statement. HB was not a stranger

to him. Furthermore, he provided HB’s mobile telephone number but said that he did

not know his full name or address. He told Constable Case, according to information

recorded in the statement given to Constable Lawrence218

that at about 5:30pm on

Sunday, 21 September 2003 he was at home. A male that he knew only as HB had

called him on his mobile telephone but he missed the call. Mr Dreelan called HB

back at about 6:00pm and asked him what he wanted. He said something important

had come up and that Mr Dreelan was in trouble and he wanted to speak to

Mr Dreelan. Mr Dreelan told him to come around and he said he would be around at

about 10:00pm. At about 10:30pm HB pulled up in the driveway at the front of

Mr Dreelan’s house in his green Nissan Skyline and revved his car loudly.

Mr Dreelan opened the front door and saw HB in the car and HB waved for him to

come out the front. Mr Dreelan went out of the front door closing it behind him and

went out to HB’s car. He opened the passenger door of the car and sat in the

passenger seat but he left the door open. HB was sitting in the drivers seat and on the

centre console of the car was a Samurai sword in its sheath. As he sat down in the car

HB picked up the sword and held it. He pulled the sword so it was halfway out of the

sheath so that Mr Dreelan could see the blade. HB then asked him “Do you know

what I do?” to which Mr Dreelan stated “No”. HB asked again “Do you know what I

do?” to which Mr Dreelan replied “I don’t want to know what you do.” HB then said

“I’m a hitman and I had a meeting with my people today and they told me that there’s

a contract out on my life (Dreelan’s life) worth $30,000.” HB said that there was a

way around it and suggested that they go inside for a chat. They got out of the car and

217

Exhibit C42 218


61

HB left the sword in the car and went to the boot of the car and opened it. HB opened

the side compartment in the boot and pulled out something wrapped in a white rag.

He unwrapped the rag in front of Mr Dreelan and inside the rag was a black revolver.

HB opened the chamber where the bullets go and spun it around a few times, he then

closed the chamber and put the gun down the front of his pants under his shirt. When

the chamber was open Mr Dreelan could not see whether there were or were not any

bullets in the gun. They walked inside the house and went straight through the lounge

and into the kitchen. In the lounge was Tanya Dunstall, Mr Dreelan’s girlfriend and

two other males whom he did not name. While in the kitchen, HB said to him words

to the effect “I know you and you’ve been good to my cousins so I will do the right

thing by you. If you give me the $30,000 I won’t kill you, I’ll forget about this”.

Mr Dreelan was scared of him so he said that he would see what he could do. HB

then opened the kitchen drawer and pulled out a very large kitchen knife. He then

said words to the effect “If you fuck with me, if you call the cops or if you get your

mates involved I’ll fucking kill you”. As HB said this he held the knife with the blade

side facing Mr Dreelan to the left of Mr Dreelan’s stomach. He then put the knife

again with the blade side facing Mr Dreelan up against the left side of Mr Dreelan’s

throat. As he held the blade against Mr Dreelan’s throat for about two seconds he

said “I’ll fucking slit your throat and cut your fucking head off”. Mr Dreelan said that

he was petrified at this point and said that he would comply but that it would take him

until the following day to get the money. He promised to call HB at 1:00pm the

following day. HB then put the knife on top of the counter, walked back to the front

door and left the house. As he went out the front door he said that he would have to

check with “his people” whether it was alright for Mr Dreelan to give him the money

and then forget about it. He told Mr Dreelan to call him in an hour to find out what

happened. Mr Dreelan shut the door of the house and quickly told his girlfriend and

this two male visitors what had happened. His girlfriend and he packed some clothes

and they left with their friends to go and stay at another friends house. At about

11:45pm he called HB’s phone. HB told him that it was all sorted out with “his

people” that Mr Dreelan could sleep easy and should call him the next day.

Mr Dreelan said that he was extremely scared of HB and believed that he would hurt

Mr Dreelan with the knife. He also believed that HB would come and get him if he

did not pay the money. Mr Dreelan had moved all of his possessions into storage and

62

could not go home to that address because HB was aware of it and Mr Dreelan did not

feel that it was safe to live there any more. Effectively, Mr Dreelan went into hiding.

14.2. As I have noted, the statement taken from Mr Dreelan was taken by Constable

Lawrence. However the reporting officer was Constable Case. Constable Case

obtained some information from Mr Dreelan for the purposes of preparing the PIR219

.

In that PIR, Constable Case recorded the suspect’s name as being “TAN, Hu”.

Constable Case gave evidence that she understood the suspect to have a surname of

“Tan” and a first name of “Hu” from her conversation with Mr Dreelan220

. However,

the statement taken by Constable Lawrence221

makes it plain that H is one word albeit

misspelt in the statement and that it is not HB’s full name.

14.3. There is a further difference between the information recorded in the statement taken

by Constable Lawrence and the information recorded by Constable Case in the PIR.

The PIR records that Mr Dreelan told Constable Case that HB had also been to the

address of Mr Dreelan’s fiancé’s brother on two occasions and asked her brother

where he could find Mr Dreelan. HB told the fiancé’s brother that he would kill him

if he did not tell him where Mr Dreelan was. Mr Dreelan told Constable Case that

“two nights ago” his fiancé’s brother was held down and two knives were held to his

throat and his gold chain was taken. Mr Dreelan said “they” were looking for him

and “they” told his fiancé’s brother that if he didn’t tell where Mr Dreelan was then

HB would kill him. The PIR also records that Mr Dreelan asserted that he had not

done anything to HB to provoke this behaviour and believed that HB considered him

to be “an easy target”.

14.4. The information thus recorded by Constable Case in the PIR222

is clearly ambiguous.

It is referring to a complaint against HB, an individual, but at more than one point it

moves into the plural, suggesting that HB has one or more accomplices. Whether this

was deliberate or not I do not know. However, Constable Case has failed to record

unambiguously and with proper clarity allegations of the utmost seriousness. This

ambiguity was noted by Deputy Commissioner Burns223

who assumed that the

reference to an incident “two nights ago” was a reference to an event two nights prior

219






63

to 21 September 2003 rather than to a more recent incident two nights before

presentation at the Holden Hill Police Station. With respect to Deputy Commissioner

Burns, I am unable to see that the reference could have been to an incident two days

prior to 21 September 2003, because the point of the confrontation with the fiancé’s

brother was to establish the whereabouts of Mr Dreelan yet, according to the

statement taken by Constable Lawrence224

, HB had had no difficulty in establishing

contact with Mr Dreelan on Sunday, 21 September 2003, having simply called him on

his mobile telephone and Mr Dreelan himself having returned that call and agreed to a

meeting later that night. The very fact that the PIR was capable of misinterpretation

in this way by the Deputy Commissioner of Police is sufficient to demonstrate its

inadequacy. Furthermore, this important information was not recorded in

Mr Dreelan’s statement by Constable Lawrence. Constable Lawrence was not called

at the Inquest and so it is not possible for me to determine whether that was because

the information was omitted by Mr Dreelan or not recorded by Constable Lawrence.

However, Mr Dreelan had obviously conveyed it earlier to Constable Case. He may

have thought that it was unnecessary to repeat himself but that is speculation.

According to the PIR225

Constable Lawrence recorded in the investigation diary at

1454 hours on 20 October 2003 that the statement had been taken and signed by

Mr Dreelan although not witnessed as no staff were available to do that. The

statement and the PIR were given to the station sergeant. The PIR investigation diary

reveals that at 1057 hours the following morning a Sergeant Johnson of the Holden

Hill Crime Management Unit forwarded the Dreelan PIR electronically to Detective

Senior Sergeant Saunders. It was not then accompanied by any hard copy. However,

at 1901 hours on the same day the hard copy was forwarded to Detective Senior

Sergeant Saunders by Sergeant Kelly of the Crime Management Unit. I should also

record that the station supervisor at the Holden Hill Police Station on day shift

20 October 2003 was Paul Bahr who was at that time a sergeant. At the time of

giving evidence he had been promoted to the rank of Inspector and is stationed at the

State Duty Office Communications Branch. He gave evidence at the Inquest and said

that for the 16 years prior to September 2003 he was a member of the Police Forensic

Services Branch. Having spent 16 years in that one area he thought it was time to

move on and seek further development within South Australia Police. He sought

224



64

secondment to an operational area226

. He said that the procedures that are used in an

operational field of South Australia Police are “vastly different” to those that he

encountered as a member of the Forensic Services Branch. He said that there were a

range of procedures that “would have been completely foreign to me”227

. Inspector

Bahr gave evidence that according to the Dreelan PIR investigation diary228

at 1325

hours on 20 October 2003 he viewed the PIR from a vetting list of PIRs taken by

those officers that he was supervising, in this instance Constables Case and Lawrence.

He acknowledged that he considered the information from Constable Case229

. He

acknowledged also that he considered the information in the statement by Constable

Lawrence which he received subsequently and that he vetted it to “make sure it

covered the relevant detail required for the particular offence under investigation”230

.

He had no recollection of the particular occasion231

but acknowledged that this must

have occurred by reference to the PIR investigation diary. Although Inspector Bahr

acknowledged that he must have vetted both the electronic PIR and the written

statement232

he offered no explanation as to why there was a different level of

information on the one hand in the PIR and on the other in the statement. He

acknowledged that it was not normal practice to have two different officers doing the

PIR and the statement, especially where there was only one statement to be taken233

.

In any event, Inspector Bahr (as he now is) failed to appreciate that there were

important details in the PIR which were simply not reflected in the statement taken by

Constable Lawrence. He also failed to recognise that the PIR entry itself was

ambiguous and to rectify that. The verb “to vet” means to examine, scrutinise and

test. Inspector Bahr’s vetting process in this instance was seriously deficient.

14.5. There was a further omission that occurred. The PIR was not recorded in the Crime

Management Journal. Although the Dreelan PIR was handled by three officers on

20 October 2003 prior to its transfer to the Crime Management Unit, none of those

officers - Constable Case, Constable Lawrence nor Sergeant (now Inspector) Bahr

made an entry in the Crime Management Journal. Inspector Bahr said:

226









65

‘As I developed some skills and knowledge and a bit more acumen in regard to the

processes used in the operational domain, I developed certain requirements that I

required my staff to enter into the investigation diary. Specifically toward the end of my

tenure I required all of my staff to enter details of any Crime Management Unit journal

entry that was also added to the crime management system and to state the particular

item or journal number for that crime management journal so that I was sure that the

matter could be cross-referenced against the journal if necessary.’234

Inspector Bahr went on to concede that there was nothing to indicate that the matter

was placed on the Crime Management Journal and that as the supervisor of

Constables Case and Lawrence it had been his responsibility to ensure that had been

done235

.

14.6. The evidence now shows that neither of the two Crime Management Unit officers

who processed the Dreelan PIR on 22 October 2003 – Sergeants Johnson and Kelly –

recorded the incident in the Crime Management Journal. Deputy Commissioner

Burns gave evidence that given the seriousness of the alleged offences in the Dreelan

PIR an entry should have been made in the Crime Management Journal236

. Deputy

Commissioner Burns was asked to comment upon General Order 8273237

which deals

amongst other things with the Crime Management Journal. Item 5 of the General

Order states that each Crime Management Unit must maintain a comprehensive real

time incident journal and the journal will contain information of interest to the

LSA/TCG and will include details which are listed. Deputy Commissioner Burns

stated that personnel within the Crime Management Unit had a responsibility to enter

information such as that contained in the Dreelan PIR in the Crime Management

Journal238

. Deputy Commissioner Burns said that if the Dreelan PIR had been entered

in the Crime Management Journal on 21 October 2003 he would have expected that it

would have been raised for discussion at the TCG meeting the following morning239

.

He also agreed that if the Dreelan PIR had been raised for discussion on 22 October

2003 it was likely that an “action” would have been raised240

. This would have meant

234




Annexure BF4 to Exhibit C11 238




66

that there would be a system in place to follow up and monitor through the TCG what

was occurring with the Dreelan PIR241

.

14.7. In the event, the Dreelan PIR was never recorded in the Crime Management Journal.

In the course of the Inquest I called for the production of minutes of the TCG

meetings at Holden Hill for the period immediately after 21 October 2003 in an effort

to identify whether the Dreelan PIR had been the subject of discussion at any TCG

meeting. However, no minutes were ever produced, notwithstanding evidence that

minutes are duly recorded and would have been recorded for the relevant period.

Deputy Commissioner Burns made an affidavit which was received as Exhibit C34.

At paragraph 70 he stated:

‘Extensive investigation has identified that relevant daily TCG documents for 2003 and

2004 are unable to be located.’

He stated that the general disposal schedule maintained in conformity with the State

Records Act requires that minutes of such meetings be held for five years after the last

action. Deputy Commissioner Burns said in his affidavit that no determination had

ever been made to destroy any TCG minutes in accordance with the State Records

Act. However, he acknowledged that the relevant minutes which must have been

taken for meetings during those years at Holden Hill Police Station TCG meetings

“have been unable to be located”. Deputy Commissioner Burns said:

‘Based on the information available to me this is a failing of SAPOL’s record keeping

system and I take responsibility for this failing.’242

14.8. Thus it was not possible at this Inquest to establish whether the Dreelan PIR was ever

raised at a TCG meeting. It certainly should have been. It was acknowledged by

Deputy Commissioner Burns and every other witness who ought to know that the

Dreelan PIR contained allegations of sufficient seriousness to require that the matter

be raised at a TCG meeting. One of the triggers for a PIR to be placed on the agenda

of a TCG meeting is information placed in the Crime Management Journal. It is

possible, in view of the omission of the Dreelan PIR from the Crime Management

Journal, that the Dreelan PIR was never placed on the agenda for a TCG meeting, but

I am unable to make a positive finding one way or another.

241


Exhibit C34, paragraph 71

67

15. The investigation of the Dreelan PIR

15.1. The next entry on the Dreelan PIR243

does not occur until 12 November 2003 when at

1400 hours Detective Senior Sergeant Saunders assigned the investigation to Senior

Constable Rohan Crawford with a computerised message as follows:

‘Dreelan threaten life – f/u suspect as discussed.’

There are no entries on the PIR investigation diary between 12 November 2003 and

13 February 2004. On 13 February 2004 Detective Senior Constable Crawford

recorded that Mr Dreelan no longer wanted to pursue the complaint. Thereafter, two

entries appear on 2 March 2004, just a few days after Christopher Wilson’s death at

the hands of HB. Those entries are as follows:

‘Enquiries made in relation to HB. Enquiries indicate suspect vehicle WWJ076 was

stopped since incident and hiding place in vehicle was searched. Nil firearm located.

Additional information received that vehicle WWJ076 has been sold. Unknown current

vehicle of HB. HH Tactical members conducted obs on [HB’s residential address] to

confirm or negate whether HB residing at address. Nil activity observed as address.

Some attention paid to HB HHill Op Nail. Appears nil result and unable to confirm

address or current vehicle.’

‘Arrangements previously made with Dreelan to attend HHPS. To date has not attend.

Advised by [blanked out] that Dreelan has moved [blanked out]. To date statement from

Dreelan is insufficient and refuses to identify additional witnesses/parties involved that

may be able to assist police (as per current statement from Dreelan) suggest matter be

filed.’

Interestingly, on 4 March 2004 a further note appears in the investigation diary

indicating that Mr Dreelan had again contacted police to explain that he had been told

that HB had been arrested for the murder at Hillcrest and that Mr Dreelan now wanted

action on his PIR. It appears that he admitted that he had not previously been

“fussed” as to what police action was taken.

15.2. Detective Senior Sergeant Saunders

Detective Senior Sergeant Saunders was unable to explain the delay between

22 October 2003 and 12 November 2003. He said:

‘There’s a three week delay and I have no independent recollection as to why there was a

three week delay. My normal business practice was that if I - if there was a delay the

reason would be recorded. I have no answer as to why I haven’t put an entry in.’244

243


68

He conceded that the allocation of the PIR may simply have been overlooked by

him245

and he implied that he could offer no excuse as to why it was not allocated246

.

Detective Senior Sergeant Saunders was invited by his Counsel and by other Counsel

to consider possible reasons for the delay in allocating the Dreelan PIR to Detective

Senior Constable Crawford. He put forward two propositions as possibilities, the first

being the delay of Mr Dreelan’s report and the fact that Mr Dreelan had since

relocated and in hiding, and secondly that the threat related to one specific victim at

one specific residence and his whereabouts were not known to the offender247

. I was

urged by Counsel for Detective Senior Sergeant Saunders not to regard these possible

reasons as actual reasons for the delay. Counsel for Detective Senior Sergeant

Saunders cautioned against looking at a speculative answer as to a possible reason for

the delay in allocation and treating it as Detective Senior Sergeant Saunders’

assessment at the relevant time. Of course I accept that Detective Senior Sergeant

Saunders has said that he has no recollection of the reason for the delay, that he does

not seek to excuse the delay. However, that begs the question of what I am to make

of answers given to him about possible reasons for the delay when asked by his own

Counsel to speculate. Detective Senior Sergeant Saunders’ response to the invitation

to speculate was to focus upon Mr Dreelan’s own delay in reporting the threat of

21 September 2003. While I accept that Detective Senior Sergeant Saunders principal

position was that he could offer no excuse for the delay, the fact remains that the

delay referred to on the part of Mr Dreelan may in fact be no delay at all; it must be

remembered that the information recorded by Constable Case in the electronic

documentation referred, albeit confusingly, to threats against Mr Dreelan’s fiancé’s

brother as recently as two days before. The information recorded by Constable Case

also referred to a deadline of seven days. All of this put some greater urgency and

immediacy upon the report by Mr Dreelan. While I accept that Detective Senior

Sergeant Saunders was not attempting to trivialise the Dreelan complaint in any way,

the very fact of referring to a delay by Mr Dreelan is misconceived when one

considers that he was actually complaining about not one threat, but two, the most

recent of which was only made two days before.

244





69

15.3. It was submitted by Counsel for Detective Senior Sergeant Saunders that if the

Dreelan PIR had been recorded in the Crime Management Journal as it should have

been, it might have been added to the agenda for a TCG meeting, and this might have

prevented the three week delay that ensued while the matter was in Detective Senior

Sergeant Saunders’ hands. So far as it goes, this may well be so. The difficulty is

that the TCG minutes are not available. Furthermore, on his own evidence Detective

Senior Sergeant Saunders would have attended the TCG meeting. Given that the PIR

was in his own hands, it is difficult to see how his attendance at a TCG meeting might

have added any more rigour to a process which was largely in his own hands. It

might be suggested that the possible actions issued by a TCG meeting would have

prevented Detective Senior Sergeant Saunders from being in a position where he was

able to overlook the PIR for three weeks. However, that is a matter of speculation.

While the failure to record the PIR on the Crime Management Journal by a number of

officers was a serious oversight, the fact remains that Detective Senior Sergeant

Saunders himself was guilty of a serious oversight in not allocating the PIR for three

weeks. It might also be said that the incoherence of Constable Case’s notation on the

electronic narrative, and Constable Lawrence’s failure to elicit that information from

Mr Dreelan for the purposes of Mr Dreelan’s statement, and Inspector Bahr’s failure

to adequately vet the PIR and ensure the correction of those errors also contributed to

a situation in which the PIR could be misconstrued if not carefully assessed by the

reader and that this did not make Detective Senior Sergeant Saunders’ task any easier.

No doubt that is true. A picture emerges of compounding errors.

15.4. Detective Senior Constable Rohan Crawford

Detective Senior Constable Rohan Crawford gave evidence at the Inquest. He said

that he instigated inquiries on the file while he had it between 12 November 2003 and

2 March 2004. He suggested that he had done computer searches in relation to the

suspect HB. He acknowledged that he was aware of the name HB from the time of,

or very shortly after, the allocation of the PIR to him.

15.5. Detective Senior Constable Crawford said that he had made observations on the HB

residence in Duthie Street, Hillcrest. He said that his primary focus was to search the

motor vehicle in which HB had travelled to Mr Dreelan’s house when the original

threat was made. It was Detective Senior Constable Crawford’s intention to search

the car in the hope of finding a weapon.

70

15.6. There is very little evidence of what was done by Detective Senior Constable

Crawford to corroborate his account, because he was not, on his own admission, in

the habit of regularly updating the electronic investigation diary with details of his

investigations and the actions he had taken. This was a very clear contravention of

South Australia Police General Orders, policies and procedures. It was suggested by

Detective Senior Constable Crawford that it was quite a common practice within

Holden Hill CIB that detectives would keep notes on paper and that entries might be

made on the electronic diary from time to time. It was said in evidence by Detective

Senior Constable Crawford that that is exactly what he did in the Dreelan

investigation. He said that he made written notes on paper and kept those notes in a

folder. After the fatal shooting of Christopher Wilson, he was asked to provide that

bundle of documents to the detectives investigating the Christopher Wilson murder.

He said that he complied with that request and that as a consequence, when he came

to make the entries on the electronic PIR investigation dairy on 2 March 2004 which

have been quoted above, he did not have access to full details of the activities he had

carried out during the period of the investigation. Upon Detective Senior Constable

Crawford referring to this paper material, I requested that Counsel for South Australia

Police arrange for searches to be instigated to produce the material to the Court. After

what I was assured were extensive and thorough searches, no such documents could

be located. The result is that there is nothing to corroborate Detective Senior

Constable Crawford’s account of the things he said he did in connection with the

Dreelan investigation. Obviously the maintenance of accurate and proper records is

important in policing as it is in any other serious endeavour. The circumstances just

described make it apparent why organisations establish systems for record keeping

and require their staff to comply with those systems. South Australia Police has such

a system; Detective Senior Constable Crawford did not comply with; as a result it is

not possible to establish precisely what was done by Detective Senior Constable

Crawford. Much of his evidence was based upon his attempts to recall what he

believed he did, but he was unable to provide explicit detail because of the absence of

records and the effluxion of time.

15.7. After he gave evidence, he was recalled to clarify the matter of the electronic searches

he claimed to have done but which were not verified by a search carried out by Senior

Constable Allan Ziegler. It was at this point in the proceedings, that Counsel for

Detective Senior Constable Crawford informed the Court that there were certain other

71

things done by Detective Senior Constable Crawford that could not be revealed

because of the public interest in maintaining the confidentiality of information that

would potentially identify an informant or human source. As I have previously

recorded, I accepted those assurances. Thus, I proceed on the assumption that in

addition to the matters about which Detective Senior Constable Crawford gave

evidence, there were other things he did.

15.8. Detective Senior Constable Crawford said, and I accept, that he had some difficulty

with Mr Dreelan in the latter’s willingness to assist with the investigation.

Ultimately, at some time in December 2003, Mr Dreelan indicated an unwillingness to

continue with the matter and this is reflected in the entry made by Detective Senior

Constable Crawford on 13 February 2004.

15.9. However, as Deputy Commissioner Burns said in his evidence, there was a second

arm to this investigation, namely that whether or not Mr Dreelan wished to pursue the

complaint about the threat to his life, there was a report that HB was in possession of

a firearm and this had to be acted upon regardless of Mr Dreelan’s attitude as a

priority and as a matter of public safety.

15.10. Detective Senior Constable Crawford was given no explanation for the delay in the

matter being allocated for investigation when he was given the PIR by Detective

Senior Sergeant Saunders. Detective Senior Constable Crawford assumed, in the

absence of any direction to the contrary, that the matter was not urgent248

.

Furthermore, during the relevant period Detective Senior Constable Crawford was

managing a heavy workload249

. Detective Sergeant Gregory Ranger said that the

Tactical Unit was not at full staffing level in 2003250

. He believed that the Tactical

Unit was understaffed to the point where it was half of its establishment251

. Senior

Sergeant Kenneth Raymond acknowledged that it was not uncommon for

investigators such as Detective Senior Constable Crawford to be overburdened by

their workload to the point where in December 2003 it was affecting the efficient

discharge of investigations252

.

248






72

15.11. Importantly, between 12 December 2003 and 2 February 2004, Detective Senior

Constable Crawford was absent on Workers Compensation leave. He had at first

thought that he would be away for a relatively short time but once he realised that he

would be absent for a matter of weeks he telephoned Senior Sergeant Raymond to

advise of the situation253

. When Detective Senior Constable Crawford returned from

Workers Compensation leave he found that no further work had been done on any of

his investigations, and in particular, not on the Dreelan PIR254

. Between 2 February

2004 and 19 February 2004 he had other urgent outstanding matters to attend to.

Between 19 February 2004 and 25 February 2004 he was required to work on an

attempted murder at Yatala Labour Prison255

.

15.12. Senior Sergeant Raymond was supervising Detective Senior Constable Crawford

from 10 November 2003 until 11 December 2003 and then again from 21 January

2004 to 22 February 2004. Detective Senior Constable Crawford said that he

discussed the Dreelan PIR with Senior Sergeant Raymond, probably soon after he

received it. He informed Senior Sergeant Raymond about his general approach to the

case, that he would like to locate the vehicle and that he had concerns that Mr Dreelan

was not being entirely cooperative and was reluctant to make a “forced entry” into

HB’s house256

. Senior Sergeant Raymond gave evidence at the Inquest. He did not

specifically recall this conversation but agreed that it was likely that it occurred and,

that it was part of his normal practice to review the investigations of those under his

supervision at an early stage after taking supervisory responsibility for a new group of

people. Senior Sergeant Raymond said that it was his habit to check his investigator’s

electronic investigation diaries periodically once or twice a month257

. Senior Sergeant

Raymond said that he did not recall speaking to Detective Senior Constable Crawford

about the way his work was progressing258

.

16. The supervision of Detective Senior Constable Crawford

16.1. Detective Senior Constable Crawford’s, Detective Sergeants during the period August

2003 until February 2004 were Detective Sergeant Ranger and Senior Sergeant

253



Transcript, pages 942, 1030, 1070 and 1120 256




73

Raymond. Further up the line of responsibility was Detective Senior Sergeant

Saunders.

16.2. Detective Sergeant Gregory Ranger

Detective Sergeant Ranger confirmed that from August 2003, Detective Senior

Sergeant Saunders took up the position of Acting Detective Senior Sergeant and

Detective Sergeant Ranger took up the position of Acting Detective Sergeant259

.

Detective Sergeant Ranger said that on 8 September 2003 he became involved in an

investigation relating to an illicit drug laboratory at Cudlee Creek. This investigation

also involved dealing with a very large quantity of stolen property which had been

found in the same premises as the Cudlee Creek laboratory. I will refer to this

investigation as the “Cudlee Creek investigation”. Detective Sergeant Ranger

described the Cudlee Creek investigation as “very big” and “a huge job”260

. Detective

Sergeant Ranger said that from 8 September 2003 into 2004 his work was exclusively

devoted to the Cudlee Creek investigation261

. He said that while he was devoted to

that investigation he believed that Senior Sergeant Raymond was responsible for the

supervision of Detective Senior Constable Crawford262

.

16.3. Detective Sergeant Ranger said that he only became aware of the Dreelan allegations

for the first time when he became involved in the investigations relevant to the

shooting of Christopher Wilson soon after the event in late February-March 2004263

.

16.4. Detective Sergeant Ranger said that Senior Sergeant Raymond was another Detective

Sergeant within the Tactical Unit at the same time as he was there. He accepted that

between 11 December 2003 and 22 January 2004 Detective Senior Sergeant Saunders

moved into a CIB management position (Detective Chief Inspector) and that Senior

Sergeant Raymond moved into the Acting Detective Senior Sergeant role that had

been vacated by Detective Senior Sergeant Saunders264

.

16.5. Detective Sergeant Ranger said that although he was not aware of the Dreelan

allegations at any time prior to late February early March 2004, if he had known of

the allegations and the allocation of the PIR to Detective Senior Constable Crawford

259







74

he would have taken action to ensure that it was investigated as expeditiously as

possible considering the seriousness of the allegation265

.

16.6. Detective Sergeant Ranger accepted that a detective sergeant is responsible for the

supervision of those members of the police force who are under his or her control266

.

Detective Sergeant Ranger said that from his point of view the Cudlee Creek matter

dominated most if not all of his time while it was a live matter within the Tactical

Unit267

. Detective Sergeant Ranger talked about responsibility for supervising less

senior staff and said that the responsibility for supervision of staff under the control of

a detective sergeant was not only the responsibility of the detective sergeant but also

of the detective senior sergeant. He said:

‘Yes, I was the only detective sergeant there, the only supervisor, no. There’s still

Detective Sergeant Raymond. Although he’s the acting senior sergeant he is still a

supervisor there.’268

16.7. Detective Sergeant Ranger acknowledged that during the period between

11 December 2003 and 22 January 2004 when Detective Senior Sergeant Saunders

was acting as detective chief inspector and Senior Sergeant Raymond was acting as

detective senior sergeant, that left himself as the only detective sergeant in the

Tactical Unit269

.

16.8. Detective Sergeant Ranger acknowledged that Detective Senior Sergeant Saunders

was aware of his involvement in the Cudlee Creek matter and that he was reporting to

Detective Senior Sergeant Saunders from time to time on that matter270

. When he was

asked if he was formally or informally relieved of the supervising role as a detective

sergeant during that period he stated:

‘Yes. I don't know whether it would've been formal, but certainly informally I would've

been told because of the lack of staff from a CIB point of view, that I was told to

complete that task and the situation is, no I wasn't told “You've now got no

responsibilities of a detective sergeant”. It was more that “This is your job to do and to

complete that task”.’271

265








75

Detective Sergeant Ranger said that it was his belief that in practice he was not

available to do any other detective sergeant duties because of his commitments with

the Cudlee Creek investigation, but nevertheless, he was continuing to be paid at a

higher duties level of detective senior sergeant272

. Detective Sergeant Ranger

acknowledged that Detective Senior Sergeant Saunders offered to assist him with his

sergeant’s responsibilities during that time273

. However in practice he felt that he was

not available to do the other Detective Sergeant duties because of his commitments to

the Cudlee Creek matter. Notwithstanding this he was continuing to be paid at a

higher duties level as Detective Sergeant throughout274

. He acknowledged that

Detective Senior Sergeant Saunders offered to assist him with the preliminary

assessment and allocation of PIRs and that he did in fact do so275

. Detective Sergeant

Ranger was asked whether it was not part of his responsibility to continue to monitor

the investigation of PIRs:

‘Well, if - I'd say that I'd been told to do the Cudlee Creek thing and, within reason and

where time permitting, fulfil my duties as a detective sergeant in the same time - where

possible.’276

He said that it was Detective Senior Sergeant Saunders who told him to work on the

Cudlee Creek matter exclusively277

.

16.9. It became apparent that by and large the bulk of the work arising out of the Cudlee

Creek matter in late 2003, was the finding of owners of a large quantity of stolen

property278

. Detective Sergeant Ranger was being assisted by a group of uniform

officers in relation to this Cudlee Creek task279

. Detective Sergeant Ranger was asked

whether it would have been possible for him during the period in question to have

conducted computer checks on the progress of PIRs and monitor the associated

investigations. He agreed that it would have been and this could have been done in a

relatively short space of time, of the order of 20 minutes280

. He said that he probably

did not undertake any such computer checks to see how his investigators were going

during this period because “I was told to complete the Cudlee Creek inquiries, that

272










76

was my main focus and that’s what I focused on”281

. However he thought it was

going a bit too far to say that he assumed that someone else was monitoring the

progress of those investigations282

. He was asked who he thought was monitoring the

staff during the period 11 December 2003 to 22 January 2004 when Senior Sergeant

Raymond was the Acting Detective Senior Sergeant and the Detective Senior

Sergeant Saunders was the Detective Chief Inspector. He said that he thought most of

the staff were helping him with the Cudlee Creek matter283


Ranger said that the staffing shortages in the Tactical Group at this time meant that

the group was understaffed to the extent of fifty percent284


Ranger acknowledged that if he had done computer checks he may have identified

that Detective Senior Constable Crawford had been allocated the Dreelan PIR and

become aware of what progress if any had been made in that investigation285

.

Detective Sergeant Ranger acknowledged that Detective Senior Constable Crawford

was on Workers Compensation leave for a significant period of approximately five

weeks in December 2003 – January 2004. He was asked if he turned his mind at any

stage to who was working on Detective Senior Constable Crawford’s investigations

during that period. He said that he did not286

. He said that he assumed that Detective

Senior Constable Crawford was being helped by other supervisors because of his

involvement in the Cudlee Creek matter287

.

16.10. Senior Sergeant Kenneth Raymond

Senior Sergeant Raymond gave evidence at the Inquest. He said that he was posted at

Holden Hill in the period between July 2003 and March 2004. He said that during

that time he did supervise Detective Senior Constable Crawford between the periods

10 November 2003 to 11 December 2003 and 22 January 2004 until 22 February

2004288

. Senior Sergeant Raymond was aware of Detective Sergeant Ranger’s

involvement in the Cudlee Creek matter289

. He said that during the period

12 December 2003 to 22 January 2004 while he was the Acting Detective Senior

Sergeant and Detective Sergeant Ranger was the only Detective Sergeant in the

281










77

division his view was that the day to day responsibility for the supervision of

Detective Senior Constable Crawford rested with Detective Sergeant Ranger290

. He

acknowledged that according to the information before the Court, Detective Senior

Constable Crawford was on Workers Compensation leave between December 2003

and January 2004. He said that during that period he would have expected that

Detective Sergeant Ranger would have monitored the progress of Detective Senior

Constable Crawford’s investigations291

. It was Senior Sergeant Raymond’s evidence

that he had no independent recollection of the Dreelan PIR. He noted that his

identification number did not appear anywhere on the Dreelan PIR investigation

diary. He knew that he had spoken to Detective Senior Constable Crawford and

another detective on his team about workloads but had no independent notes or

memory as to the specifics of the conversations292

. Senior Sergeant Raymond

acknowledged that he was, in effect, Detective Senior Constable Crawford’s

supervisor between 14 November 2003 and 11 December 2003 and again from

21 January 2004 until 22 February 2004293

and that during that period he did not

recall ever being concerned about the status of any of Detective Senior Constable

Crawford’s files294

. He had no recollection of Detective Senior Constable Crawford

having telephoned him to advise that Detective Senior Constable Crawford was

required to undergo shoulder surgery in December 2003295

.

16.11. Conclusions as to supervision of Detective Senior Constable Crawford

In my view, during the period October 2003 to February 2004 Detective Senior

Constable Crawford had little or no supervision. Detective Sergeant Ranger

continued to be paid at a higher duties rate as a detective sergeant and had not been in

any formal sense relieved of his supervisory responsibility but devoted himself to his

Cudlee Creek investigation and carried out little or no supervision outside of the

Cudlee Creek matter. It is true that when Senior Sergeant Raymond first arrived in

November 2003, he sat down with Detective Senior Constable Crawford and

discussed his files. Beyond that, Detective Senior Constable Crawford was

substantially left to his own devices. It is plain from Detective Senior Sergeant

290



Exhibit C27 293




78

Saunders’ affidavit296

that he understood that Detective Sergeant Ranger would

continue to spend time with less experienced staff, provide leadership and during this

period, because of staffing shortages and workloads in the Tactical Unit, Detective

Senior Sergeant Saunders “volunteered” to assume some of Detective Sergeant

Ranger’s duties. The roles which he “voluntarily assumed” in addition to his own

duties were receiving all PIR/IR’s for assessment and allocation which would

normally have been sent directly to Detective Sergeant Ranger. This assistance was

limited to conducting preliminary checks in relation to drug information reports to

determine whether they would be allocated for further investigation. Furthermore,

Detective Senior Sergeant Saunders agreed to accepting responsibility for the vetting

of arrest/report/expiation files297

.

16.12. Detective Senior Sergeant Saunders also made reference to the Cudlee Creek matter

and said that the staff shortages and workloads to which he referred were partly

attributable to that matter. Detective Senior Sergeant Saunders said that two separate

case management files were created in relation to the laboratory and the stolen

property and that Detective Sergeant Ranger managed both matters which were

overseen by Detective Senior Sergeant Saunders. He said that the property case

management in particular was lengthy and time consuming and involved property

tracing and conducting a public viewing to try and identify as much property as

possible. He said that the property aspect of this investigation comprised 111 actions

issued to Detective Sergeant Ranger and other members of the Tactical Unit.

16.13. It is a matter of concern that the Cudlee Creek property investigation occupied so

much time and was accorded such a high priority by comparison with other matters,

including the Dreelan PIR, which would appear to me to warrant a higher level of

priority than the search for the owners of stolen property.

16.14. It is a matter of considerable concern that during the lengthy period during which

Detective Senior Constable Crawford was on Workers Compensation leave no

supervisor including Detective Sergeant Ranger, Senior Sergeant Raymond and

Detective Senior Sergeant Saunders made any attempt to reallocate his duties to

anyone else. During this considerable period, it appears that Detective Senior

Constable Crawford’s investigations simply languished. This is even more serious

296

Exhibit C31 297

Exhibit C31

79

when one considers that there was a general problem with understaffing throughout

the period, as a result of which one might expect that Detective Senior Constable

Crawford would have had urgent matters that had not been attended to even before he

was absent on Workers Compensations leave. That would have made all the more

crucial the need to monitor his investigations during that period.

17. The fate of the Dreelan PIR

17.1. As I have already noted, Mr Dreelan contacted police after the death of Christopher

Wilson and requested that his complaint against HB be reactivated. I think it can be

fairly said that by at the latest 13 February 2004 the Dreelan PIR had reached a point

at which Detective Senior Constable Crawford was no longer actively pursuing it. On

2 March 2004, after the death of Christopher Wilson, Detective Senior Constable

Crawford made the entries in the PIR investigation diary which I have set out

previously in this Finding. Those entries, although made after the death of

Christopher Wilson, make no mention of HB’s arrest for Christopher Wilson’s

murder. That is surprising. Detective Senior Constable Crawford’s explanation for

the entries was that he had been asked to pass the PIR over to Sergeant Paul

Blackmore. That in itself was triggered by the fatal shooting of Christopher Wilson.

It seems rather artificial that there was no mention of the fatal shooting of Christopher

Wilson in those diary entries, or at the very least a reference to HB’s arrest for

murder.

17.2. The affidavit of Detective Sergeant Ranger which was admitted as Exhibit C23

annexes a statement prepared by him as to his further actions in relation to the

Dreelan PIR in March 2004. The statement was, I understand, prepared in December

2004. The statement indicates that Detective Sergeant Ranger was unable to procure

the cooperation of witnesses to the Dreelan complaint apart from Mr Dreelan himself.

Neither Mr Dreelan’s fiancé nor other witnesses were prepared to provide statements.

The offences of which HB was convicted on 4 August 2005298

do not include any of

the Dreelan PIR allegations. It appears that the Dreelan PIR was ultimately filed as

foreshadowed by the diary entry made by Detective Senior Constable Crawford on 2

March 2004.

298

See paragraph 2.1 hereof

80

17.3. In many ways the Dreelan PIR was overtaken by the fatal shooting of Christopher

Wilson. The Dreelan PIR involved not only the threat against Mr Dreelan, but it had

what was referred to by Deputy Commissioner Burns as a second arm to the

investigation namely, the simple possession or possible possession of a firearm by

HB. Deputy Commissioner Burns in his evidence was firmly of the view that this

aspect of the matter required action regardless of Mr Dreelan’s attitude because it did

not necessarily require Mr Dreelan’s full cooperation or support to pursue that line of

enquiry. Furthermore, it was a priority because of the issue of public safety and

acting swiftly where a firearm is involved.

17.4. Although I must accept that there were actions taken by Detective Senior Constable

Crawford that he was unable to reveal in open Court, and of which I am unaware, I

think I can proceed safely on the assumption that no member of South Australia

Police confronted HB at any time between October 2003 and 25 February 2004 with

the allegation that he was in possession of a firearm contrary to Condition 5 of his

obligation to the Youth Court. There were a number of powers in relation to the

firearm that could have been exercised pursuant to the Firearms Act 1977. These

include:

(a) A member of the police force may seize a firearm if he or she suspects on

reasonable grounds that a person who has possession of it is not a fit and proper

person to have possession of it,

(b) A member of the police force may seize a firearm if he or she suspects on

reasonable grounds that continued possession of a firearm by a person would be

likely to result in undue danger to life or property,

(c) A member of the police force may seize a firearm if he or she suspects on

reasonable grounds that a person has possession of the firearm in contravention

of an order of a Court,

(d) A member of the police force may stop, detain and search or detain and search

any vehicle on which the member suspects on reasonable grounds there is a

firearm liable to seizure under this Act,

81

(e) A member of the police force may stop, detain and search or detain and search

any person who the member suspects on reasonable grounds has possession of a

firearm liable to seizure under this Act,

(f) A member of the police force may break into, enter and search any premises in

which the member suspects on reasonable grounds there is a firearm liable to

seizure under this Act,

(g) A person who hinder or resists a member of the police force acting in the

exercise of powers conferred under the Act is guilty of an offence299

.

17.5. There is nothing to suggest that any member of South Australia Police exercised any

of these powers.

18. Deputy Commissioner Gary Burns

18.1. Deputy Commissioner Gary Burns made an affidavit which set out South Australia

Police’s “corporate” response to the matters the subject of this Inquest. The affidavit

was received as Exhibit C34 in these proceedings. Deputy Commissioner Burns also

gave oral evidence. Deputy Commissioner Burns was open and frank in his evidence

and conceded that the circumstances preceding the death of Christopher Wilson

presented opportunities for greater leadership to be demonstrated by members of

South Australia Police and that he would have expected greater leadership to have

been shown.

18.2. In particular, Deputy Commissioner Burns said that he would have expected the

“human source” information to have been given some priority for investigation

because it involved a firearm. He would have expected CIB, because of their

expertise, to become involved. He regarded the responsibility as resting with

Detective Senior Sergeant Saunders to seek and secure extra resources because the

information that a person is in possession of a revolver was something that he would

expect to be investigated and acted upon at an early time300

.

18.3. Deputy Commissioner Burns said that he did not consider it unusual or irregular that

the human source information in this case was not widely disseminated amongst

299

Sections 32 and 33, Firearms Act 1977 300


82

police at Holden Hill but that even in circumstances where it is not widely

disseminated he would expect that it be acted upon with expedition.

18.4. Deputy Commissioner Burns referred to the time taken by Detective Senior Sergeant

Saunders to allocate the Dreelan PIR. He said that he did not consider that it should

have taken so long to allocate bearing in mind the gravity of the allegations301

.

18.5. Deputy Commissioner Burns noted the significant amount of time off work that

occurred by reason of the work related injury suffered by Detective Senior Constable

Crawford and said that during Detective Senior Constable Crawford’s absence he

would have expected that a matter involving allegations of a serious nature such as the

Dreelan PIR would continue to be investigated302

.

18.6. Deputy Commissioner Burns said that Mr Dreelan’s reluctance to press the matter

was a factor to be weighed in the investigation but regardless of Mr Dreelan’s

cooperation there remained information that a particular person had recently been in

possession of a firearm which he had threatened to use. This was a matter that

continued to warrant investigation by police and there was sufficient information to

continue to pursue that aspect of the matter303

. In relation to the initial report of the

first shooting of Christopher Wilson, Deputy Commissioner Burns remarked that all

police members involved in the event should have been aware that it was a serious

offence which posed a real risk to the community. He said that the established

procedure for dealing with serious offences should have been activated and it was

not304

.

18.7. Deputy Commissioner Burns noted that the General Duties manual instructions in

relation to firearms305

makes it clear that any officer investigating or receiving a

report of a firearms incident, including any use of a firearm in unlawful

circumstances, must submit an ancillary report to the Firearms Branch through the

Local Service Area Intelligence Section. It appears that General Order was not

complied with either on the occasion of the Dreelan PIR or of the first Christopher

Wilson shooting report.

301

Exhibit C34, paragraph 45 302




Annexure BF16 to Exhibit C11 (affidavit of Assistant Commissioner Brian Fahy)

83

18.8. Deputy Commissioner Burns said that active consideration should have been given to

recalling the CIB on the night of 25/26 February 2004306

. Deputy Commissioner

Burns was also critical of the failure to take statements from two of the witnesses who

were present on the night of 25/26 February 2004307

.

18.9. Deputy Commissioner Burns acknowledged that the report of the first Christopher

Wilson shooting should have been accorded greater urgency and priority and been

treated as a serious offence and if that had happened the route which the investigation

ultimately took would have been avoided308

.

18.10. Deputy Commissioner Burns said that he believed that the first Christopher Wilson

shooting incident may have been treated differently by police had it been reported on

the street or at the scene via telephone or a passing patrol. He thought that the

investigation “took a slower route” in light of it being reported in the police station

where reports of firearms offences are rare309

. In saying this Deputy Commissioner

Burns was not seeking to excuse the deficiencies exposed in this Inquest, he was

making an observation which is probably true. But the mode of reporting a matter to

police should not affect the manner of investigation. Deputy Commissioner Burns

acknowledged that incorrect value judgements and assessments as to seriousness were

made on the night of 25/26 February 2004 and that the matter was given a lower

prioritisation than was justified or warranted in the circumstances310

.

18.11. Deputy Commissioner Burns pointed to a number of changes to practices, procedures,

policies and General Orders within South Australia Police which, he said, should

assist in preventing a repetition of the shortcomings he identified. However, none of

the changes identified by him were instigated as a direct result of the Christopher

Wilson shooting. The changes are set out in Deputy Commissioner Burns’ affidavit,

Exhibit C34.

306


Exhibit C34, paragraphs 62 and 63 308




84

19. Submissions by the Commissioner of Police

In closing submissions filed on behalf of the Commissioner of Police, the

Commissioner identifies a number of issues arising from the conduct of the inquiry

and the investigations on the night of 25/26 February 2004. They are as follows:

1. The failure to identify the incident reported on 25 February 2004 as a serious

incident and follow the General Order procedures for investigation of a serious

offence.

2. On 25 February 2004, CIB's decision to provide advice rather than a more

detailed analysis and assessment of the evidence. CIB did not assume

investigative responsibility.

3. Failure to obtain statements from all witnesses who attended the Holden Hill

Station on 25 February 2004.

4. Advice of the vehicle description involved in the incident and warning of

potential weapon possession was not forwarded to all patrols in the Holden Hill

Local Service Area.

5. Christopher Wilson was not offered medical attention or advised to seek

medical attention upon presenting at Holden Hill Police station with a

wound.

6. There was a failure to identify and secure all physical evidence on the night of

25 February 2004 including bullet fragments from the car and the scene of the

shooting, the victim's clothing, and an assessment of the car.

7. There was an excessive length of time taken for the Dreelan PIR to be allocated

by Acting Detective Senior Sergeant Saunders to an investigating officer.

8. Once allocated, the nature of Detective Senior Constable Crawford's

investigation of the Dreelan PIR and the lapse of investigations whilst Detective

Senior Constable Crawford was on leave.

9. The lack of priority and urgency in investigation of human source information

received in late 2003.

85

20. Conclusions as to deficiencies in policing preceding the death of Christopher

Wilson

In no particular order I list the deficiencies I have identified in the police work that

preceded the death of Christopher Wilson and which I regard as part of the

circumstances of his death:

1. The failure to act on the human source information expeditiously because of

resource shortages.

2. The failure by Constable Denise Case to adequately complete the Dreelan PIR.

3. The failure by Constable Lawrence to include in Mr Dreelan’s statement the

reference to the later threats against Mr Dreelan’s fiancé’s brother.

4. The failure by Inspector Bahr to identify the differences between the PIR as

recorded by Constable Case and the statement as taken by Constable Lawrence.

5. The failure of Constable Case to enter the Dreelan complaint in the Crime

Management Journal.

6. The failure of Constable Lawrence to enter the Dreelan complaint in the Crime

Management Journal.

7. The failure of Inspector Bahr to enter the Dreelan complaint in the Crime

Management Journal.

8. The failure of Constable Case to notify the Firearms Branch in accordance with

General Orders of the allegation of an offence involving a firearm.

9. The failure of Constable Lawrence to notify the Firearms Branch in accordance

with General Orders of the allegation of an offence involving a firearm.

10. The failure of Inspector Bahr to notify the Firearms Branch in accordance with

General Orders of the allegation of an offence involving a firearm.

11. The fact that Inspector Bahr was then the officer in charge at the Holden Hill

Police Station when the Dreelan complaint was made, when on his own

evidence he was inexperienced in operational policing.

86

12. The failure of Sergeant Kelly of the Crime Management Unit to enter the

Dreelan complaint in the Crime Management Journal.

13. The failure of Sergeant Johnson to enter the Dreelan complaint in the Crime

Management Journal.

14. The failure of Detective Senior Sergeant Saunders to ensure that the human

source information was pursued with sufficient expedition and urgency and

appropriate resources allocated.

15. The failure of Detective Senior Sergeant Saunders to allocate the Dreelan PIR

for a period of three weeks.

16. The failure of Detective Senior Constable Crawford to maintain a timely PIR

investigation diary as required by General Orders.

17. The failure by any member of South Australia Police to exercise powers that

were available under the Firearms Act following the making of the Dreelan PIR.

18. The failure by any member of South Australia Police to confront HB with the

serious allegations that had been made by Mr Dreelan311

.

19. Detective Sergeant Ranger was preoccupied with the return of stolen property

from the Cudlee Creek investigation to the detriment of at least the investigation

of the Dreelan allegations which involved a threat to life and were therefore

clearly more serious and deserving of a higher priority.

20. Senior Sergeant Raymond and Detective Sergeant Ranger failed to

communicate adequately between them as to who was supervising Detective

Senior Constable Crawford.

311

It may be suggested that even if this had occurred HB would have merely denied the allegations. He might

have had warning and been able to dispose of a firearm. While all that may be true, it seems to me

unfortunate that he was left for a period of months between October and February 2004 in the knowledge

that he had made an extremely serious threat against the life of another person with a view to extorting a

significant sum of money from that person, and there appeared to be no consequence flowing from his

behaviour. This could only increase his confidence and bravado. It must be remembered, that he was, after

all, only 17 years old during this period. I do not suggest that a further intervention would have prevented

him from obtaining another firearm and eventually killing Christopher Wilson or some other person;

however in my view an opportunity was lost which might potentially have had that result.

87

21. Detective Senior Sergeant Saunders failed to ensure that either Detective

Sergeant Ranger or Senior Sergeant Raymond were maintaining effective

supervision of Detective Senior Constable Crawford.

22. During Detective Senior Constable Crawford’s absence on Workers

Compensation leave Detective Sergeant Ranger failed to ensure that Detective

Senior Constable Crawford’s investigations, including the Dreelan PIR, were

being investigated.


Compensation leave Senior Sergeant Raymond failed to ensure that Detective

Senior Constable Crawford’s investigations, including the Dreelan PIR, were

being investigated.


Compensation leave Detective Senior Sergeant Saunders failed to ensure that

Detective Senior Constable Crawford’s investigations, including the Dreelan

PIR, were being investigated.

25. The failure by any person to pursue the fact that HB was in possession of a

firearm and that this could be pursued regardless of Mr Dreelan’s attitude.

26. The fact that Detective Sergeant Ranger thought he had been relieved of his

supervisory responsibilities in light of his Cudlee Creek investigation and that

his supervisor, Detective Senior Sergeant Saunders, had a different perception.

27. The fact that the Holden Hill CIG tactical section was understaffed to a

significant extent (by a factor, on one account, of as much as 50 percent).

28. The fact that the PIR as recorded by Constable Case referred to “Hu Tan” rather

than H and this was not reconciled with the more accurate information in the

statement obtained by Constable Lawrence from Mr Dreelan.

29. The failure by Senior Constable Redding to appreciate at an early stage that

Christopher Wilson was complaining that he had been shot by a firearm.

30. The failure to ensure that productive use was made of the timely searches

carried out by Probationary Constable Tina Crawford.

88

31. Senior Constable Redding’s flawed judgement in deciding that the matter was

less serious because Christopher Wilson was withholding information and

behaving nonchalantly.

32. Senior Constable Redding’s transmission of this wrong impression to other

officers present on the night including Sergeant Mickan, Detective Green and

Detective Wilson all of whom were influenced by it.

33. The failure by Senior Constable Redding and Sergeant Mickan to ensure that

statements were taken on the night from the two remaining witnesses, Mark

Wilson and Ryan Williams.

34. The failure by any police officer involved on the night to search James

McAinsh’s vehicle.

35. The failure by any police officer involved on the night to advise a more senior

officer, possibly the State Duty Officer, of the situation and seek guidance.

36. The belief by uniformed police officers, Senior Constable Redding and Sergeant

Mickan, that the CIB officers had accepted responsibility for the further

investigation of the matter.

37. The belief by the CIB officers, Detective Green and Detective Wilson, that they

had not assumed any responsibility for the further investigation of the matter

and were merely “advising”.

38. The net failure of any of officers, Sergeant Mickan, Senior Constable Redding,

Detective Wilson or Detective Green to assume leadership when it must have

been obvious to all of them that there was a real danger that the matter would

not be under the control and management of one of the uniformed officers or the

CIB members.

39. The failure of Senior Constable Redding or Sergeant Mickan to update the PIR

once the statements of Dylan Connelly and James McAinsh were obtained to

eliminate references to a “slug gun” and to substitute a reference to a “pistol or

revolver” with the result that the Holden Hill LSA Intelligence Section daily

89

briefing prepared the following morning contained a reference to a slug gun312

and that the Holden Hill Crime Management Journal, presumably prepared by

Senior Constable Redding, contained a reference to a slug gun313

with the

possible result that Detective Senior Sergeant Douglas may have missed an

opportunity to elevate the matter to a higher priority at the Crime Management

Unit meeting on Thursday morning.

40. The determination by Senior Constable Redding, Sergeant Mickan, Detective

Wilson and Detective Green, none of whom had ballistics training, that a

projectile which was known to have ricocheted from a hard surface was, in all

probability, merely a slug from an air gun.

41. The failure to alert Holden Hill Patrols as to the fact that a person was at large

with a weapon and a preparedness to use it.

42. The failure by any of the officers present in Holden Hill Police Station to have

taken the opportunity while the men were present at the police station to take

one of them back to Duthie Street and identify the house involved (I have

reached no conclusion one way or another about whether a specific offer was

made by any of the Christopher Wilson group that night to this effect: even it

was not offered, it could still have been suggested by police).

43. The failure by Senior Constable Redding to ensure that all five of the witnesses

were accounted for as far as statements were concerned before he allowed them

to leave that night.

44. The assumption by Detectives Wilson and Green that they would not have been

given overtime or authorisation to continue with the investigation that night314.

45. The failure by Detectives Wilson and Green at least to attempt to seek the

authorisation of a more senior officer to remain on duty that night.

312



Had Detectives Wilson and Green stayed longer they would have become aware of the involvement of a

revolver, they might have ensured that all statements were taken that night and they could not have failed to

become aware of the result of Probationary Constable Crawford’s searches if, as they both asserted, they

truly did not become aware of these searches on the night.

90

46. The failure by Sergeant Kelly to allocate the Christopher Wilson PIR to

Detective Sergeant Addison who was Acting Officer in Charge of CIB Team 2.

Instead, Sergeant Kelly allocated the PIR to Detective Sergeant Butvila who

was at that time acting in a different position.

47. Sergeant Kelly failed to have regard to the Holden Hill CIB disposition sheet, a

document readily available either in hard copy or on the intranet.

48. The failure by both Detective Sergeant Butvila and Detective Sergeant Addison

to have put in place procedures to ensure that one or other was checking to make

sure that any files that were potentially misallocated would be checked and

recovered from the respective pigeon holes of Detective Sergeant Butvila and

Detective Sergeant Addison, and that the respective PIMS logons for Detective

Sergeant Addison and Detective Sergeant Butvila would be routinely checked to

ensure that no PIRs had been misallocated during a period of acting.

49. The failure by South Australia Police to preserve minutes of TCG meetings as

required by the State Records Act.

21. The aftermath of the Christopher Wilson shooting – What did South Australia

Police do?

21.1. I have already referred to the complaint made to the Police Complaints Authority by

Mrs Julie Wilson on 19 April 2004315

. I was not aware, until I received the affidavit

of Deputy Commissioner Burns316

that there had in fact been another internal

complaint by Superintendent Bronwyn Killmeir. That complaint was dated 15 April

2004. The Court was not aware of the existence of that complaint until the receipt of

Deputy Commissioner Burns’ affidavit, Exhibit C34, shortly before Deputy

Commissioner Burns gave evidence on 20 November 2007. That day was the twenty-

second sitting day and the last day on which evidence was taken in the Inquest. The

Court has never been provided with a copy of the complaint by Superintendent

Killmeir. According to the affidavit of Deputy Commissioner Burns, Superintendent

Killmeir (now Assistant Commissioner, Killmeir) reported on 15 April 2004 to

Superintendent Tank of the Internal Investigation Branch that there were “service

delivery deficiencies” relating to the investigation of the shooting of Christopher

315

Exhibit C12g 316

Exhibit C34

91

Wilson317

. I do not know whether the service delivery deficiencies complained of by

Superintendent Killmeir extended to the deficiencies that I have identified in the

handling of the Dreelan PIR, or the human source information.

21.2. This referral, by Superintendent Killmeir, of a complaint about service delivery faults,

was the only recognition by South Australia Police that something had gone wrong.

21.3. The relevant officers who proceeded to investigate the murder of Christopher Wilson

had not been involved in the earlier investigations (with the exception of Detective

Sergeant Ranger). HB pleaded guilty to the murder in July 2005 and was sentenced

on 4 August 2005. On 6 September 2005, South Australia Police submitted a

Coroners report to the Office of the State Coroner318

. That report was tendered as

Exhibit C34c. It consists of three pages and attaches a copy of Sentencing Remarks

of the Honourable Justice White. The report sets out in very brief summary form a

description of the first encounter between the Christopher Wilson group and HB. It

sets out a short summary of the events of the early hours of the morning of Saturday,

28 February 2004 which resulted in the fatal shooting of Christopher Wilson. The

only reference to the handling by the police of the first complaint by Christopher

Wilson is as follows:

‘A short time later the occupants attended the Holden Hill Police Station to report the

incident. Statements were taken from Christopher Wilson, Dylan Connelly and James

McAinsh. No other police action was taken. This matter is now the subject of a Police

Complaints Authority investigation.’319

21.4. In my opinion, the Police Complaints Authority is not an appropriate body for dealing

with problems such as those apparent in this case. The problems that emerged in this

Inquest were of a cultural nature, more than a disciplinary nature, subject to one or

two exceptions. From South Australia Police point of view, the cultural problems are

far more pressing than the disciplinary problems. The Police Complaints Authority

process is effectively conducted in secret. It is still not clear to me what the outcome

of Superintendent Killmeir’s referral was. Nothing has been produced to me by South

Australia Police to show that.

21.5. The Commissioner was requested voluntarily to reveal the full Internal Investigation

Branch investigation and Police Complaints Authority assessment and other relevant 317


Exhibit C34, Item 40 319

Exhibit C34c

92

material including statements made by the key witnesses in this Inquest to the Internal

Investigation Branch. The Commissioner refused to reveal it citing as his reason the

fact that the disciplinary processes under the Police Complaints Act were yet to be

completed320

. That the disciplinary processes had not been completed more than three

and a half years after they were instigated is a matter of considerable concern and

Deputy Commissioner Burns conceded this in his evidence321

. So far as I am aware,

the disciplinary process has resulted in no more serious sanction than unrecorded

reprimands, submission to counselling in relation to conduct and recorded

reprimands322

. It is difficult to see how the public interest in the full disclosure to an

inquest of all matters pertinent to the circumstances preceding the death of

Christopher Wilson could be outweighed by the perceived public interest in the

prevention of possible prejudice to a disciplinary process that appears likely to result

in nothing more serious than recorded and unrecorded reprimands and managerial

guidance.

21.6. In my opinion, the Inquest was detrimentally affected by the statutory secrecy that is

central to the Police Complaints and Disciplinary process. Any forensic investigation,

any thorough legal review, indeed any normal legal process has as one of its

hallmarks the full disclosure of previous accounts of the events given by witnesses

before the inquiry. That did not happen at this Inquest.

21.7. As the Inquest proceeded, some witnesses revealed that they had been subject to a

disciplinary assessment. That information was not known to the Court in relation to

that witness until the witness revealed it. It was not until very late in the Inquest that,

at the express request of the Court, Counsel for the Commissioner provided a

complete list of all officers who had been subject to disciplinary assessment. In my

opinion, this was potentially relevant information. Information that is potentially

relevant is habitually disclosed to Courts voluntarily by Government agencies such as

South Australia Police, because the Government has a duty to behave as a model

litigant. That this did not occur in this case is probably explained by the secrecy

320

I do not wish to be taken as suggesting that the Commissioner does not have the right, under section 48, to

refuse to reveal this information. To the contrary, he does have that right, as affirmed by recent Supreme

Court authority (White & Ors v The State of South Australia & Ors [2007] SASC 75). However, the

decision to exercise the right and to refuse to provide the information may nevertheless be the subject of

examination and comment by me. In this case, the Commissioner offered a reason for his refusal, namely

the disciplinary processes not yet completed. I am entitled to comment on the reason given by the

Commissioner and express my opinion as to its merits. This I will proceed to do. 321


See recommendations contained letter from Police Complaints Authority, Exhibit C12n

93

governing the Police Complaints and Disciplinary process. It is difficult to see how

an organisation such as South Australia Police could really justify withholding

relevant information from the Coroner’s Court on the basis that there is still the

possibility that the police complaints process may, after three and half years, yield

some further result which, it seems to me, is likely to be no more significant than a

reprimand (recorded or unrecorded) or managerial guidance.

21.8. In submissions filed on behalf of the Commissioner, it was put that the Police

Complaints Authority and the Internal Investigation Branch inquiry in relation to any

particular police officer, or more generally at all, is not relevant to the cause and

circumstances of the death of Christopher Wilson. That response overlooks the fact

that during the course of the Inquest evidence was adduced by a number of witnesses

who were either known at the time, or who came to be known during the course of

their evidence, as persons who had given previous statements to the Internal

Investigation Branch and/or officers of the Police Complaints Authority. Any proper

forensic inquiry into a matter in which the participants have given previous written

accounts of their involvement cannot be complete without a consideration of those

previous accounts, and a consideration of whether those accounts are consistent with

the accounts being provided to the current inquirer. For that reason, the material was

clearly relevant, and had it not been for the secrecy provisions of the Police

Complaints Act, I would unhesitatingly have sought and considered that material.

21.9. It was further submitted by the Commissioner as follows:

‘In this incident, like most matters which are the subject of Coronial Inquests, there a

(sic) combination of factors which have come together to cause the judgment calls made

by individuals on the night. The individual roles and decisions of police officers have

been subject to inquiry by SAPOL. The more relevant issue is to consider the SAPOL's

corporate policies and procedures….’

I strongly disagree with any suggestion that the conduct of particular officers and the

judgement calls made by them is a subject outside the scope and jurisdiction of an

Inquest. The fact of the matter is that, apart from section 48 of the Police Complaints

Act, some of the information flowing from the investigation of the conduct of

individual officers whether made by South Australia Police of anyone else, might

provide relevant information for consideration by the Coroner at an Inquest. It is not

difficult to see that this might arise, and might likely arise, in the context of a death in

police custody. In my opinion, it is not satisfactory to suggest that the coronial

94

inquiry must, in every case, if it is to be conducted with the benefit of all relevant

information, await the completion of police complaints processes which can take as

long as three and a half years, and perhaps more, to complete. This is a matter that

requires attention by the Parliament. I intend to recommend that consideration be

given to the making of amendments to section 48 of the Police Complaints Act to

remove the barrier created by the secrecy provision to full disclosure of all relevant

evidence to the Coroner’s Court in future.

21.10. I have made a number of references in this Finding to my concern at the lack of an

overarching coronial investigation that would have enabled the Court to predict with

some degree of certainty the likely course of the Inquest and the witnesses who would

be likely to be required. The Commissioner made submissions in relation to that

issue. The submission is as follows:

‘SAPOL provided its report into the death of Christopher Wilson to the Coroner on 6

September 2005. The Coroner never provided any criticism, feedback nor request that

any further investigation be conducted as a result of SAPOL submitting this report. In

the event that the Coroner (sic) Office is of the view that a Coroner's Report provided by

SAPOL requires further investigation or supplementation SAPOL is happy to provide

this if requested to do so.’

I have already referred to the coronial report provided on 6 September 2005 and to the

extremely brief description of the police handling of the first Christopher Wilson

complaint. Nothing in the report could have alerted the reader to the existence of the

Dreelan PIR, nor to the human source information. All of these things were relevant

to the circumstances surrounding the death of Christopher Wilson. I do not suggest

that the deficiencies in the Dreelan investigation or in the handling of the human

source information were causative of Christopher Wilson’s death. The most that can

be said of their relevance to the actual cause of Christopher Wilson’s death is that a

number of opportunities were afforded for interventions which might have had the

potential to prevent HB from continuing to behave as he did and to engage in the kind

of conduct he did which included ultimately the shooting of Christopher Wilson.

However, it is indisputable that the events surrounding the handling of the Dreelan

PIR and the human source information were relevant to the circumstances of

Christopher Wilson’s death and the Court has jurisdiction pursuant to section 21 of

the Coroners Act to consider not only cause but circumstances of a reportable death.

“Circumstances” is a word of very wide import, and I am firmly of the view that the

95

behaviour of HB during the twelve months of the eighteenth year of his life leading to

the fatal shooting of Christopher Wilson, including as they did, various acts of

violence involving weapons and firearms that resulted in the placement of warnings

on the Police Information Management System about him, and ultimately in a

complaint by Mr Dreelan about him threatening the latter’s life, are quite plainly

circumstances which are relevant to the fatal shooting by HB of Christopher Wilson.

21.11. It is disingenuous to suggest that a coronial report which says nothing at all about

these matters is a proper coronial report. The Commissioner suggests that it is always

possible for the Coroner to request further investigations. The difficulty with this is

that when the initial information is as scant as that provided in this case, there is little

reason to request a further investigation. Furthermore, out of the approximately two

thousand deaths reported each year, there are police reports associated with

approximately one thousand of them. The Coroner’s Court simply does not have the

resources to consider each one of the thousand or so police reports received each year

to test their adequacy. There are several thousand police officers in South Australia

while the staff of the Coroner’s Court numbers less than twenty. It is beyond the

resources of the Court to examine each South Australia Police investigation to assess

its adequacy. The State Coroner and the Coroner’s Court must be able to rely upon a

thorough initial investigation by South Australia Police. Any such investigation may

require supplementation. However, the extent of supplementary investigation should

usually be minor. In the present case a three page investigation – namely that

provided and referred to by the Commissioner as the “Coroner’s report” in this matter

on 6 September 2005 – has been dwarfed by the volume of evidence oral and written

elicited at this Inquest.

21.12. The Commissioner has submitted that the matter of documents required to be held by

South Australia Police pursuant to the State Records Act for periods required by that

Act are not “part of the cause and circumstances of death of Christopher Wilson”323

.

I take this to imply that this matter therefore does not concern the Coroner’s Court. In

my view, that is incorrect. The unavailability of documents relevant to an Inquest is

very much a matter for the concern of the Coroner’s Court. In the present case, the

documents asserted by Detective Senior Constable Crawford to afford evidence of his

efforts in pursuing the Dreelan PIR cannot be found after extensive searches by South

323

Closing submissions for Commissioner of Police

96

Australia Police. They are required to be preserved by reason of the State Records

Act 1997. Furthermore, the minutes of TCG meetings during 2003 and 2004 which

would have revealed for the Court the deliberations of the TCG in relation to both the

Dreelan PIR (if any) and the Christopher Wilson PIR have not, after extensive

searches, been located by South Australia Police. They should have been retained by

reason of the State Records Act 1997. In my opinion, the Coroner’s Court is entitled

to take notice of those matters and to record its concern at the fact that documents

required to be kept in accordance with the law of this State have not been so kept.

I formally record my concern at that circumstance.

22. Section 63C – Young Offenders Act 1993

22.1. Section 63C of the Young Offenders Act 1993 provides as follows:

‘(1) A person must not publish, by radio, television, newspaper or in any other way, a

report of proceedings in which a child or youth is alleged to have committed an

offence, if—

(a) the court before which the proceedings are heard prohibits publication of

any report of the proceedings; or

(b) the report—

(i) identifies the child or youth or contains information tending to

identify the child or youth; or

(ii) reveals the name, address or school, or includes any particulars,

picture or film that may lead to the identification, of any child or

youth who is concerned in those proceedings, either as a party or a

witness.

(2) The court before which the proceedings are heard may, on such conditions as it

thinks fit, permit the publication of particulars, pictures or films that would

otherwise be suppressed from publication under subsection (1)(b).

(3) A person who contravenes this section, or a condition imposed under

subsection (2), is guilty of an offence.

Maximum penalty: $10 000.’

22.2. Section 63C is capable of having an application to the allegations against HB. I will

proceed on the assumption that even after his conviction, at least of the offences of

which he was convicted in July and August 2005, references to allegations

underpinning those convictions might still attract the operation of section 63C. That

is because, notwithstanding the ultimate conviction of HB, the matters complained of

against him can still be described as allegations, or could have been up until his

conviction. Furthermore, there are the allegations the subject of the Dreelan PIR

97

which were never brought before a Court324

. It may be that in those circumstances the

allegations contained in the Dreelan PIR would not if published fall within the

prohibition in section 63C because that section seems only to apply to proceedings

before a Court. Finally, there are the allegations that were the subject of HB’s earlier

convictions for his offences in March 2003. Notwithstanding the fact that those

allegations resulted in convictions, or at least findings of guilt, they nevertheless

would have been allegations prior to that time, and it seems to me that section 63C

must be interpreted on the assumption that the subsequent conviction of a person of

allegations against them does not permit thereafter the publication of information

identifying the child or tending to identify the child.

22.3. In my view the Coroner’s Court, in publishing its finding of the cause and

circumstances of the death of Christopher Wilson, is not prohibited by section 63C

from referring to HB by name and otherwise identifying him. The prohibition in

section 63C does not in my opinion apply to a Court. Nor does it apply in my opinion

to prevent the receipt of information by the Coroner’s Court, or any other Court, of

information which would otherwise be prohibited from publication by section 63C. I

am of that view because the prohibition in section 63C applies to “a person” and this

expression is not apt to include a “Court”. In Canadian Pacific Tobacco Company

Limited and Anor v Stapleton (1952) 86 CLR 1 Chief Justice Dixon said that the

meaning of the words “to any person”, “probably cannot apply to Courts, which

would hardly be called persons”. A similar view was expressed by Gibbs J in Miller v

Miller (1978) 141 CLR 269 at 277. In Hilton v Wells (1985) 157 CLR 57, Mason and

Dean JJ referred to Dixon CJ’s comments and held that a provision which prohibited

divulging or communicating information to “another person” did not apply in respect

of the disclosure of such information in the course of giving evidence before a Court.

Their Honours commented that “as a matter of ordinary language, the words ‘divulge

or communicate to another person’ are inappropriate to refer to the giving of evidence

before a Court”. The majority judgment of Gibbs CJ, Wilson and Dawson JJ in

Hilton v Wells (at 76) made reference to the comments of Gibbs J in Miller v Miller

(1978) 141 CLR 269, and went on to find that “relevant evidence obtained from an

intercepted communication may be given in proceedings” other than those mentioned

in the legislative provision, and that the provision of such evidence did not amount to

324

The section may now operate in relation to the proceedings before the Coroner’s Court, which have now

aired the allegations.

98

an offence under the Act. I have concluded that the prohibition in section 63C did not

prevent the divulgence of information about HB to the Coroner’s Court and further

that it would not operate to prohibit me from making reference in my finding to

proceedings in which HB was alleged to have committed an offence in such a way as

to identify him.

22.4. The effect of section 63C it seems to me would be to prohibit the publication by

newspaper, radio or television of a report of this finding if that report identified HB by

name or otherwise tended to identify him. I note that section 63(2) permits the Court

before which the proceedings relating to the allegations against the child have been

heard to make an order permitting publication of material that would otherwise be

suppressed from publication under subsection (1). The Coroner’s Court, not being the

Court before which the proceedings against HB were heard, does not have power to

permit the publication of particulars that would identify HB. Had subsection (2)

empowered me to do so, I would certainly have made an order permitting the

publication of HB’s name and other identifying information. My reason for that is

that there has been a significant public interest in this Inquest, and it is generally in

the public interest that inquests be conducted as fully as possible under public

scrutiny. I propose to recommend that section 63C be amended to permit the

Coroner’s Court to make an order permitting publication of the name of a youth. An

obvious situation in which that might be necessary is that in which a child, remanded

in custody, dies while in custody. It is not difficult to envisage that the circumstances

leading up to a child being charged with the offence that leads to his or her remand in

custody would be relevant to the circumstances of his or her incarceration, and if he or

she died as a result of a self-inflicted injury, may very well be relevant to the

circumstances of that death. Section 63C would prevent the publication of a report of

such an inquest in which the child was identified. That may not always be

appropriate. In my opinion, the Coroner’s Court should have the power to permit

publication. A similar difficulty arises with section 59A of the Children’s Protection

Act 1993, which is identical to section 63C but applicable to child welfare

proceedings before the Children’s Court. Such proceedings are likely to be relevant

in an inquest into the death of the child the subject of the proceedings and so a

corresponding amendment should be made to section 59A.

99

23. Recommendations

23.1. Section 25(2) of the Coroners Act 2003 provides that the Court may add to its

findings any recommendation that might, in the opinion of the Court, prevent, or

reduce the likelihood of, a recurrence of an event similar to the event that was the

subject of the Inquest.

23.2. I have not found that the death of Christopher Wilson was caused by any of the

deficiencies in policing which I have identified in these findings. However, I do

believe that a number of the deficiencies identified by me can be regarded as events,

which had they been handled differently, might potentially have changed future

events, including possibly, the ultimate event the subject of this Inquest, namely the

fatal shooting of Christopher Wilson. These events were opportunities for

intervention which had the potential to directly or indirectly prevent that fatal

outcome. While those events were not causes of the fatal outcome, they were

components of the circumstances leading up to the fatal event.

23.3. Each of the potential opportunities for intervention relates to acts or omissions of

police officers. Those acts or omissions have been, in some sense, deficient. The

system for dealing with those deficiencies is the process established by the Police

Complaints Act. It was that process that Superintendent Killmeir adopted to deal with

the deficiencies she identified. In my opinion, improvements to the process

established by the Police Complaints Act might reduce the likelihood of a recurrence

of deficiencies of the kind identified during this Inquest and therefore have the

potential to reduce the likelihood of a recurrence of an event similar to the event that

was the subject of this Inquest.

23.4. The Police Complaints Act or the Police (Complaints and Disciplinary Proceedings)

Act 1985 to use its full title, was enacted in 1985. The Act has remained in

substantially the same form since that time although there have been nine amending

Acts in the twenty-three years since 1985 which have made various adjustments to the

general scheme of the Act. However, none of those amending Acts has made any

major change to the system which remains broadly as it was in 1985.

23.5. Since 1985, Queensland Police (the Fitzgerald Royal Commission 1989), New South

Wales Police (the Wood Royal Commission 1994), Western Australia Police (the

Kennedy Royal Commission 2002) and the Australian Federal Police (the Fisher

100

Review 2003) each have undergone significant reform processes following Royal

Commissions or Inquiries.

23.6. In Victoria, the Office of Police Integrity published a report called “A Fair and

Effective Victoria Police Discipline System” in October 2007. That report

recommended substantial changes to the Victorian model of complaint handling and

disciplinary process within Victoria Police. It noted that in Tasmania and South

Australia there has been little reform in this area by comparison with Queensland,

New South Wales, Western Australia, the Federal Police, and Victoria itself. Of

course, Victoria has seen the establishment of the Office of Police Integrity which in

itself represents a reform. The report notes that the Victorian system is similar to that

of South Australia although it is even more complex than the South Australian

system.

23.7. The South Australian Act is indeed complex. The fact that proceedings can take more

than three and a half years is clear evidence of that fact. In Police Service Board v

Russell John Morris and Robert Colin Martin (1985) 156 CLR 397 Brennan J, as he

then was, said:

‘Internal disciplinary authority over members of the police force is a means - the primary

and usual means - of ensuring that individual police officers do not jeopardize public

confidence by their conduct, nor neglect the performance of their police duty, nor abuse

their powers. The purpose of police discipline is the maintenance of public confidence in

the police force, of the self-esteem of police officers and of efficiency.’

23.8. In Hardcastle v Commissioner of Police [1984] 53 ALR 593 at 597 the Full Federal

Court said:

‘The purpose of a disciplinary system within a professional organisation is: to protect the

public, to maintain proper standards of conduct and to protect the reputation of the

organisation. It is not to punish.’

23.9. In my opinion this Inquest has shown that the Police Complaints and Disciplinary

process in South Australia is in need of review. As noted in the Victorian Office of

Police Integrity report325

an effective disciplinary process must operate promptly. A

delayed outcome with lingering uncertainty is often stressful for the employee

concerned and may well be worse than the penalty itself. It is also a potential cause of

dysfunction within the workplace.

325

“A Fair and Effective Victoria Police Discipline System”, page 20

101

23.10. I therefore recommend as follows:

1. I recommend that the Government review the Police (Complaints and

Disciplinary Proceedings) Act 1985 in light of reforms adopted in other States

of Australia, the United Kingdom and New Zealand326

.

2. In the meantime I recommend that section 48 of the Police Complaints Act be

amended to remove the barrier created by the secrecy provision to full

disclosure of al relevant evidence to the Coroner’s Court.

3. I recommend that section 63C of the Young Offenders Act 1993 and section

59A of the Children’s Protection Act 1993 be amended to permit the

Coroner’s Court to allow publication of material that would otherwise be

prohibited from publication by these provisions.

326

See generally, “A Fair and Effective Victoria Police Discipline System”, Office of Police Integrity, Victoria,

October 2007.

Key Words: Firearms - licence - Firearms Act; Murder – allegations; Police; Police

Complaints; Public safety; Publicity/Public Warnings

In witness whereof the said Coroner has hereunto set and subscribed his hand and

Seal the 7th

day of April, 2008.

State Coroner

Inquest Number 12/2007 (0599/04)

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